Transitional Care LSW Intern

WESTERN RESERVE AREA AGENCY ON AGING•North Olmsted, OH

8d•Onsite

About The Position

The Transitional Care Coach Intern supports members during critical transitions of care following discharge from a hospital, skilled nursing facility, emergency department, or observation stay. This role focuses on post-discharge assessments, education, care coordination, and connection to community resources to promote safe transitions, improved outcomes, and reduced readmissions.

Requirements

Actively enrolled in a Master’s in Social Work Program
Active, unrestricted licensure as Licensed Social Worker (LSW)
Bachelor’s degree required in Social Work
Proficiency with electronic health records and documentation systems.
Able to travel within Lake, Lorain, Medina, Geauga, and Cuyahoga counties.

Responsibilities

Conduct a thorough in-person or 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
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