Telehealth Care Coach LPN

WESTERN RESERVE AREA AGENCY ON AGING•Cleveland, OH

1d•Remote

About The Position

Western Reserve Area Agency on Aging (WRAAA) is seeking a Telehealth Care Coach LPN to support members during critical transitions of care after discharge from a hospital, skilled nursing facility, emergency department, or observation stay. This role focuses on post-discharge assessments, education, care coordination, and connecting members to community resources to ensure safe transitions, improve outcomes, and reduce readmissions. WRAAA is a private non-profit corporation serving as the planning, coordinating, and administrative agency for aging programs in Cuyahoga, Geauga, Lake, Lorain, and Medina Counties, working within Ohio's public aging services network to help Ohioans receive needed services and age successfully in their homes and communities.

Requirements

Active, unrestricted licensure as an LPN.
Proficiency with electronic health records and documentation systems.

Nice To Haves

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

Responsibilities

Conduct a thorough telephonic Care Transitions Assessment for members recently discharged from acute care settings.
Perform Falls Risk Assessment.
Perform Social Determinants of Health (SDOH) Assessment.
Provide member education on diagnosis-specific red flags and symptoms requiring follow-up.
Provide member education on medication understanding and adherence.
Review and use 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, and follow up on referrals and resource connections.
Document 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.