Transitional Care Coach (PRN)

About the Role

The Transitional Care Coach provides short-term post-discharge support to individuals transitioning from hospitals, skilled nursing facilities, emergency departments, and observation stays back into the community. Through assessments, education, medication reconciliation, and care coordination, the Transitional Care Coach helps ensure members understand their care plan, access needed resources and avoid unnecessary hospital readmissions. This role is ideal for professionals who enjoy working independently while making a direct impact on patient outcomes and quality of life.

Responsibilities

• Conduct comprehensive care transition assessments including in-home or telephonic assessments with recently discharged members covering fall risk assessments, social determinants of health (SDOH) assessments, medication reconciliation (if an RN), and review of discharge instructions and follow-up care needs
• Educate and empower members through individualized education regarding diagnosis-specific warning signs and red flags, medication management and adherence, self-management strategies, use of personal health records, and appropriate follow-up with healthcare providers
• Coordinate care and connect resources by identifying barriers that may impact recovery or independence, connecting members with community-based services and supports, collaborating with healthcare providers, care managers, and community organizations, and promoting continuity of care across healthcare settings
• Maintain accurate documentation of assessments, interventions, and member interactions in accordance with program requirements, completing documentation within 48 hours of member contact
• Support organizational excellence by adhering to all program requirements, clinical standards, organizational policies, and regulatory guidelines, and performing other duties as assigned

Qualifications

• Active, unrestricted Ohio license as a Registered Nurse (RN), Licensed Social Worker (LSW, LISW, LISW-S), or Licensed Practical Nurse (LPN)
• Strong assessment, communication, and documentation skills
• Comfortable using electronic documentation and health record systems
• Reliable transportation and ability to travel throughout Cuyahoga, Geauga, Lake, Lorain, and Medina Counties

Preferred Qualifications

• Multistate licensure
• Experience in care transitions, care management, home health, population health, community-based services, hospital discharge planning, or managed care programs

Compensation

• $45.00 for each completed telephonic assessment
• $80.00 for each completed home-visit assessment
• This position is compensated on a per diem basis

Benefits

• Six-week PTO program and thirteen paid holidays
• $750.00 annual investment in professional development through training funds
• 401K program with company match
• Paid parking in a covered parking garage
• Medical, dental, and vision benefits

Reports to: Care Transitions Supervisor | FLSA Status: Per Diem