Telehealth Care Coach LSW
Western Reserve Area Agency on Aging, Cleveland, OH, United States
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 with local service provider organizations and the Ohio Department of Aging (ODA) to form the state's public aging services network. The network works together to create opportunities for Ohioans to receive needed home and community services and support and to age successfully in their homes and communities.
Position Overview:
The Telehealth Care Coach 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 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
Active, unrestricted licensure as Licensed Social Worker (LSW, LISW or LISW-S)
Bachelor's degree required
Master's degree Preferred
Experience in care transitions, care management, home health, population health, or community-based care preferred.
Proficiency with electronic health records and documentation systems.
If you are interested in joining our talented team of professionals, please complete the application and submit your resume. We look forward to hearing from you!
The Agency is committed to providing equal employment and advancement opportunities to all. Employment decisions are made based on each person's performance, qualifications, and abilities. The Agency does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, sex, national origin, age, disability status, health status, genetic information or ancestry, protected veteran status, sexual orientation, gender identity or expression, or any other protected characteristic.
Western Reserve Area Agency on Aging's Equal Employment Opportunity policy covers all aspects of employment practices, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.
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 with local service provider organizations and the Ohio Department of Aging (ODA) to form the state's public aging services network. The network works together to create opportunities for Ohioans to receive needed home and community services and support and to age successfully in their homes and communities.
Position Overview:
The Telehealth Care Coach 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 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
Active, unrestricted licensure as Licensed Social Worker (LSW, LISW or LISW-S)
Bachelor's degree required
Master's degree Preferred
Experience in care transitions, care management, home health, population health, or community-based care preferred.
Proficiency with electronic health records and documentation systems.
If you are interested in joining our talented team of professionals, please complete the application and submit your resume. We look forward to hearing from you!
The Agency is committed to providing equal employment and advancement opportunities to all. Employment decisions are made based on each person's performance, qualifications, and abilities. The Agency does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, sex, national origin, age, disability status, health status, genetic information or ancestry, protected veteran status, sexual orientation, gender identity or expression, or any other protected characteristic.
Western Reserve Area Agency on Aging's Equal Employment Opportunity policy covers all aspects of employment practices, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.