Telehealth Care Coach RN

WESTERN RESERVE AREA AGENCY ON AGING • Cleveland, OH

1d • Remote

About The Position

The Telehealth Care Coach supports members during critical transitions of care following discharge from a hospital, skilled nursing facility, emergency department, or observation stay. This role may be filled by a Registered Nurse (RN) and focuses on post-discharge assessments, education, care coordination, and connection to community resources to promote safe transitions, improved outcomes, and reduced readmissions.

Requirements

• Active, unrestricted licensure as an RN.
• 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 preferred.

Responsibilities

• Conduct a thorough 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 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: Assesses 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.
• Meet monthly productivity and capacity expectations.
• Adhere to all organizational policies, regulatory requirements, and professional scope-of-practice guidelines.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 101-250 employees