RN Transitional Care Coach - Post-Discharge Navigator

Western Reserve Area Agency On Aging; North Olmsted (OH); On-site; USD 59,000 - 72,000; Full time

Benefits offered by this job

Six weeks PTO

13 holidays

401K with match

Medical/Dental/Vision

Job summary

Western Reserve Area Agency on Aging in North Olmsted, OH, seeks a Transitional Care Coach (RN) to guide members through post-discharge transitions, focusing on assessments, education, care coordination, and connection to community resources to reduce readmissions.

Responsibilities include in-person or telephonic Care Transitions Assessments, medication reconciliation support, patient education, identifying gaps in care, and documenting all interactions within 48 hours.

Qualifications

• Active, unrestricted RN licensure required.
• Multistate license preferred.
• Experience in care transitions, care management, or home health preferred.

Responsibilities

• Conduct Care Transitions Assessments post-discharge (in person or by phone).
• Coordinate with providers, care managers, and community agencies to support continuity of care.
• Provide medication reconciliation support and patient education on meds and red flags.
• Document all interactions within 48 hours and meet productivity expectations.

Skills

Care transitions experience

Patient education

Team collaboration

Education

RN license

Tools

EHR systems

Job description

Western Reserve Area Agency on Aging in North Olmsted, OH, seeks a Transitional Care Coach (RN) to guide members through post-discharge transitions, focusing on assessments, education, care coordination, and connection to community resources to reduce readmissions.

Responsibilities include in-person or telephonic Care Transitions Assessments, medication reconciliation support, patient education, identifying gaps in care, and documenting all interactions within 48 hours.