Transitional Care Coach (PRN)

Western-Reserve-Area-Agency-On-Aging; North Olmsted (OH); On-site; USD 42,000 - 65,000; Part time

Benefits offered by this job

Six-week PTO

Professional development funds

401K with company match

Paid parking

Medical, Dental, Vision benefits

Job summary

Western Reserve Area Agency on Aging (WRAAA) in Ohio seeks a Transitional Care Coach (PRN) to provide post-discharge support. You will conduct telephonic and in-home assessments, educate members on their care plans, coordinate with providers, and document interactions in a timely manner.

Qualified candidates hold an Ohio RN or LSW license, with strong assessment and communication skills and the ability to travel across multiple counties.

Qualifications

• Active, unrestricted Ohio license (RN or LSW).
• Strong assessment and documentation skills.
• Ability to travel across multiple counties.

Responsibilities

• Conduct in-home or telephonic post-discharge assessments.
• Educate members on care plans, meds, red flags, and self-management.
• Coordinate care with providers and community resources.
• Document assessments and interactions within 48 hours.
• Ensure regulatory compliance and organizational standards.

Education

RN license

LSW license

Tools

Electronic health records

Job description

Job Details Job Location: Corporate - North Olmsted, OH 44070 Position Type: Per Diem Education Level: License - LPN, RN, or LSW Reports to: Care Transitions Supervisor FLSA Status: Per Diem

The Transitional Care Coach (PRN) position is compensated on a per diem basis, with payment of $45.00 for each completed telephonic assessment and $80.00 for each completed home-visit assessment.

Our Mission:

We provide choices for people to live independently in the place they want to call home.

About Us:

Western Reserve Area Agency on Aging (WRAAA) is a private non-profit corporation, organized and designated by the State of Ohio to be the planning, coordinating and administrative agency for federal and state aging programs in Cuyahoga, Geauga, Lake, Lorain and Medina Counties. It is one of twelve Area Agencies on Aging (AAAs) in the state organized together with local service provider organizations and the Ohio Department of Aging (ODA) to form the state's public aging services network. The network works together to create opportunities for Ohioan's to receive needed home and community services and supports; and to age successfully in their own homes and communities.

Candidates we love…

• Self-motivated and compassionate Social Workers (LSWs) and Registered Nurses (RNs) looking to be part of a Best-in Class organization
• Team players who are committed to providing superior service to all they serve
• Enthusiastic professionals excited to grow with an organization that values dedication, innovation and collaboration.

What our staff loves about us…

• A generous six-week PTO program and thirteen paid holidays
• A $750.00 investment in professional development through a substantial, annual training funds allotment
• A 401K program with company match
• Paid parking in a covered parking garage
• Medical, Dental, Vision Benefits and so much more…

Position Summary:

The Transitional Care Coach provides short-term post-discharge support to individuals transitioning from hospitals, skilled nursing facilities, emergency departments, and observation stays back into the community.

Through assessments, education, medication reconciliation, and care coordination, the Transitional Care Coach helps ensure members understand their care plan, access needed resources and avoid unnecessary hospital readmissions. This role is ideal for professionals who enjoy working independently while making a direct impact on patient outcomes and quality of life.

Job Duties:

Conduct Comprehensive Care Transition Assessments

Complete in-home or telephonic assessments with recently discharged members, including:

• Fall Risk Assessments
• Social Determinants of Health (SDOH) Assessments
• Medication Reconciliation (if an RN)
• Review of discharge instructions and follow-up care needs

Educate and Empower Members

Provide individualized education regarding:

• Diagnosis-specific warning signs and red flags
• Medication management and adherence
• Self-management strategies
• Use of Personal Health Records
• Appropriate follow-up with healthcare providers

Coordinate Care and Connect Resources

• Identify barriers that may impact recovery or independence
• Connect members with community-based services and supports
• Collaborate with healthcare providers, care managers, and community organizations
• Promote continuity of care across healthcare settings

Maintain Accurate Documentation

• Document assessments, interventions, and member interactions in accordance with program requirements
• Complete documentation within 48 hours of member contact

Support Organizational Excellence

• Adhere to all program requirements, clinical standards, organizational policies, and regulatory guidelines
• Perform other duties as assigned

Qualifications

• Active, unrestricted Ohio license as:
  • Registered Nurse (RN)
  • Licensed Social Worker (LSW, LISW, LISW-S)
• Strong assessment, communication, and documentation skills
• Comfortable using electronic documentation and health record systems
• Reliable transportation and ability to travel throughout:
  • Cuyahoga County
  • Geauga County
  • Lake County
  • Lorain County
  • Medina County
• Preferred:
  • Multistate licensure
  • Experience in:
    • Care Transitions
    • Care Management
    • Home Health
    • Population Health
    • Community-Based Services
    • Hospital Discharge Planning
    • Managed Care Programs

The Agency is committed to providing equal employment and advancement opportunities to all. Employment decisions are made based on each person’s performance, qualifications, and abilities. The Agency does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, sex, national origin, age, disability status, health status, genetic information or ancestry, protected veteran status, sexual orientation, gender identity or expression, or any other protected characteristic.

Western Reserve Area Agency on Aging’s Equal Employment Opportunity policy covers all aspects of employment practices, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.