Telephonic Care Coach

WESTERN RESERVE AREA AGENCY ON AGING•Cleveland, OH

29d•$21 - $24

About The Position

Dedicate 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 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 Ohioans to receive needed home and community services and support and to age successfully in their homes and communities. Reports to: Care Transitions Supervisor Position Overview: 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), Licensed Social Worker (LSW), or Licensed Practical Nurse (LPN) 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 RN, LPN, or LSW.
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.
Perform all other duties as assigned