Transitional Care LSW Intern

Western-Reserve-Area-Agency-On-Aging; North Olmsted (OH); On-site; USD 21,000 - 28,000; Part time

Job summary

Western Reserve Area Agency on Aging in Ohio seeks a Transitional Care Coach Intern to support members through post‑discharge transitions, coordinating care, education, and connections to community resources to promote safe, reduced readmissions.

The role includes in-person or telephonic assessments, documenting interactions within 48 hours, and collaborating with providers, care managers, and social services while traveling across Lake, Lorain, Medina, Geauga and Cuyahoga counties.

Qualifications

• MSW enrollment required and ongoing.
• LSW licensure required or active licensure.
• Proficiency with electronic health records and documentation systems.

Responsibilities

• Conduct Care Transitions Assessment for recently discharged members.
• Provide education on red flags, symptoms, medications and adherence.
• Review member's Personal Health Record and identify care gaps.
• Connect members to community resources and coordinate with providers and agencies.
• Complete two post-discharge follow-up calls to assess health status and reinforce plans.
• Document all interactions within 48 hours in the designated system.
• Meet monthly productivity and capacity expectations.
• Travel within Lake, Lorain, Medina, Geauga and Cuyahoga counties.

Skills

Care coordination

Documentation

Travel within counties

EHR proficiency

Education

Master's in Social Work

Licensed Social Worker (LSW) licensure

Enrollment in MSW program

Bachelor's degree in Social Work

Job description

Reports to: Social Work SupervisorFLSA Status: InternshipDedicate 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 older 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 professionals looking to be part of a Best-in Class organizationTeam players who are committed to providing superior service to all they serveEnthusiastic professionals excited to grow with an organization that values dedication, innovation and collaboration.Position Summary: The Transitional Care Coach Intern supports members during critical transitions of care following discharge from a hospital, skilled nursing facility, emergency department, or observation stay. This role focuses on post-discharge assessments, education, care coordination, and connection to community resources to promote safe transitions, improved outcomes, and reduced readmissions.Job Duties:Conduct a thorough in-person or telephonic Care Transitions Assessment for members who have recently been discharged from acute care settings, ensuring all activities are performed within the established scope of practice, including:Falls Risk AssessmentSocial Determinants of Health (SDOH) AssessmentProvide member education on:Diagnosis-specific red flags and symptoms requiring follow-upMedication understanding and adherenceReview and use of the member’s Personal Health RecordIdentify gaps in care and connect members to appropriate community-based and social support resources.Coordinate with providers, care managers, and community agencies to support continuity of care.Complete two post-discharge follow-up calls to:Assesses for changes in health statusReinforce education and discharge plansFollow up on referrals and resource connectionsDocument all member interactions, assessments, and interventions within 48 hours in the designated system.Meet monthly productivity and capacity expectations.Adhere to all organizational policies, regulatory requirements, and professional scope-of-practice guidelines.Perform all other duties as assignedActively enrolled in a Master’s in Social Work ProgramActive, unrestricted licensure as Licensed Social Worker (LSW)Bachelor’s degree required in Social WorkProficiency with electronic health records and documentation systems.Able to travel within Lake, Lorain, Medina, Geauga, and Cuyahoga counties.If you are interested in joining our dynamic team of professionals, please click “Apply” to submit your qualifications. We look forward to hearing from you!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.