Care Transitions Clinician

WESTERN RESERVE AREA AGENCY ON AGING • Cleveland, OH

13d • $50,000 - $60,000

About The Position

The Care Transitions Clinician provides participant-centered transitional care services to support older adults and their caregivers during care transitions. This role conducts assessments, delivers education and coaching on health conditions, medications, and self-management, and connects participants to appropriate community and agency resources.

Requirements

• Active, unrestricted licensure as RN, LPN, or LSW in the applicable state.
• Ability to work independently in the field and manage time effectively.
• Proficiency with electronic health records and documentation systems.
• Reliable transportation for home visits, if applicable.
• Ability to travel throughout our five-county region (Cuyahoga, Geauga, Lake, Lorain, and Medina).

Nice To Haves

• Experience in care transitions, care management, home health, population health, or community-based care preferred.

Responsibilities

• Conduct in-home visits or telephonic interventions with members recently discharged from inpatient or observation settings.
• Perform a comprehensive Care Transitions Assessment, within scope of practice, including:
• Falls Risk Assessment
• Social Determinants of Health (SDOH) Assessment
• Medication Reconciliation (RN only)
• Provide member education on:
• Diagnosis-specific red flags and symptoms requiring follow-up
• Medication understanding and adherence
• Review and use of the member’s Personal Health Record
• Identify 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:
• Assess for changes in health status
• Reinforce education and discharge plans
• Follow up on referrals and resource connections
• Document all member interactions, assessments, and interventions within 48 hours in the designated system.
• Manage an assigned caseload and meet monthly productivity and capacity expectations.
• Adhere to all organizational policies, regulatory requirements, and professional scope-of-practice guidelines.
• Perform all other duties as assigned

Benefits

• A Competitive Salary
• A generous six-week PTO program with thirteen paid holidays
• A $ 750.00 investment in professional development through a substantial, annual training funds allotment
• A 401K program with a company match
• Medical, Dental, Vision Benefits options
• 72.5 cents per Mileage reimbursement
• Free parking and so much more…

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed