Transitional Care Coach (PRN)

Western Reserve Area Agency On Aging; North Olmsted (OH); On-site; USD 32,000 - 54,000; Part time

Job summary

Western Reserve Area Agency on Aging seeks a Transitional Care Coach (PRN) to provide post-discharge support, assessments, and care coordination in the North Olmsted area.

The role requires active Ohio RN/LSW/LPN licenses, strong assessment and documentation skills, and ability to travel across local counties. Per diem compensation is paid per telephonic and home-visit assessment, contributing to better patient outcomes.

Qualifications

• Active, unrestricted Ohio license as RN, LSW, or LPN.
• Strong assessment, communication, and documentation skills.
• Willing to travel across Cuyahoga, Geauga, Lake, Lorain, and Medina Counties.

Responsibilities

• Conduct comprehensive Care Transition Assessments (in-home or telephonic) with recently discharged members.
• Educate and empower members on diagnosis-specific signs, medications, and self-management.
• Coordinate care and connect members with community-based services and supports.
• Maintain accurate documentation in accordance with program requirements and 48-hour window.
• Support organizational standards and regulatory guidelines; perform other duties as assigned.

Skills

RN license

LSW license

LPN 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.

Dedicate yourself to an Organization and Mission you can be proud of by joining the Western Reserve Area Agency on Aging!

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)
  • Licensed Practical Nurse (LPN)
• 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.