Transitional Care Coach (RN)
About The Position
The Transitional Care Coach (RN) supports members during critical transitions of care following discharge from a hospital, skilled nursing facility, emergency department, or observation stay. The role focuses on post-discharge assessments, education, care coordination, and connection 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. It is a full-time, exempt position reporting to the Care Transitions Supervisor.
Requirements
- Active, unrestricted Registered Nurse licensure.
- Proficiency with electronic health records and documentation systems.
- Ability to travel within Lake, Lorain, Medina, Geauga, and Cuyahoga counties.
Nice To Haves
- Multistate nursing license preferred.
- Experience in care transitions, care management, home health, population health, or community-based care preferred.
Responsibilities
- Conduct in-person or telephonic Care Transitions Assessments for members recently discharged from acute care settings, including falls risk and Social Determinants of Health assessments and medication reconciliation.
- Assist non-RN 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 with 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.
- Follow organizational policies, regulatory requirements, and professional scope-of-practice guidelines.
- Perform other duties as assigned.
Benefits
- Six-week PTO program
- Thirteen paid holidays
- Annual professional development training funds
- 401(k) with company match
- Medical benefits
- Dental benefits
- Vision benefits
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
