Transitional Care Coach (RN)

Reports to: Care Transitions Supervisor

FLSA Status: Exempt

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 together with local service provider organizations and the Ohio Department of Aging (ODA) to form the state's public aging services network. The network collaborates together to create opportunities for older Ohioan's to receive needed home and community services and supports; and to age successfully in their own homes and communities.

Candidates we love…

• Self-motivated and compassionate professionals looking to be part of a Best-in Class organization
• Team players who are committed to providing superior service to all they serve
• Enthusiastic professionals excited to grow with an organization that values dedication, innovation and collaboration.

What our staff loves about us…

• A generous six-week PTO program and thirteen paid holidays
• An investment in professional development through a substantial, annual training funds allotment
• A 401K program with company match
• Medical, Dental, Vision Benefits and so much more…

Position Summary: 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. This role focuses on post-discharge assessments, education, care coordination, and connection to community resources to promote safe transitions, improved outcomes, and reduced readmissions.

Job Duties:

• 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
• Medication Reconciliation
  • Will assist non-RN staff in completing Medication Reconciliation according to HEDIS requirements.
• 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