Transitional Care LSW Intern — Shape Safe Transitions

Western-Reserve-Area-Agency-On-Aging; North Olmsted (OH); Presencial; USD 21.000 - 28.000; A tiempo parcial

Descripción de la vacante

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.

Formación

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

Responsabilidades

• 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.

Conocimientos

Care coordination

Documentation

Travel within counties

EHR proficiency

Educación

Master's in Social Work

Licensed Social Worker (LSW) licensure

Enrollment in MSW program

Bachelor's degree in Social Work

Descripción del empleo

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.