Transitional Care Coach (LPN)

WESTERN RESERVE AREA AGENCY ON AGING • North Olmsted, OH

3d • $25 - $0 • Onsite

About The Position

The Transitional Care Coach (LPN) 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 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 full-time and reports to the Care Transitions Supervisor.

Requirements

• Active, unrestricted licensure as a Licensed Practical Nurse (LPN).
• 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 in-person or telephonic Care Transitions Assessments for recently discharged members, within the established scope of practice.
• Complete falls risk, Social Determinants of Health (SDOH), and medication reconciliation assessments.
• Assist non-LPN staff with medication reconciliation according to HEDIS requirements.
• Educate members about diagnosis-specific warning signs and symptoms requiring follow-up, medication understanding and adherence, and 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 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) program with company match.
• Medical, dental, and vision benefits.

What This Job Offers

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