Transitional Care Coach (LSW)

WESTERN RESERVE AREA AGENCY ON AGING • North Olmsted, OH

3d • $60,600 - $0

About The Position

The Transitional Care Coach (LSW) supports members during critical care transitions after discharge from a hospital, skilled nursing facility, emergency department, or observation stay. The role focuses on post-discharge assessment, education, care coordination, and connections to community resources to promote safe transitions, improved outcomes, and reduced readmissions. The position is based at the Corporate location in North Olmsted, Ohio, and requires travel within Lake, Lorain, Medina, Geauga, and Cuyahoga counties.

Requirements

• Active, unrestricted licensure as a Licensed Social Worker (LSW).
• Proficiency with electronic health records and documentation systems.
• Ability to travel within Lake, Lorain, Medina, Geauga, and Cuyahoga counties.

Nice To Haves

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

Responsibilities

• Conduct thorough in-person or telephonic Care Transitions Assessments for members recently discharged from acute care settings, within the established scope of practice.
• Complete Falls Risk and Social Determinants of Health assessments and medication reconciliation.
• Assist non-LSW staff with medication reconciliation according to HEDIS requirements.
• Educate members about diagnosis-specific red flags and symptoms requiring follow-up, medication understanding and adherence, and review and use of their 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 changes in health status, reinforce education and discharge plans, and follow up on referrals and resource connections.
• Document member interactions, assessments, and interventions in the designated system within 48 hours.
• Meet monthly productivity and capacity expectations.
• Adhere to organizational policies, regulatory requirements, and professional scope-of-practice guidelines.
• Perform other duties as assigned.

Benefits

• Six-week paid time off program.
• Thirteen paid holidays.
• Annual professional development training funds.
• 401(k) program with company match.
• Medical, dental, and vision benefits.

What This Job Offers

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