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.

Reports to: Director of Business Operations

FLSA Status: Non-Exempt

Candidates we love…

• Self-motivated and compassionate individuals 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 Competitive Salary
• A generous six week PTO program with thirteen paid holidays
• A $ 750.00 investment in professional development through a substantial, annual training funds allotment
• A 401K program with a company match
• Medical, Dental, Vision Benefits options
• Mileage reimbursement
• Free parking and so much more…

Position Summary:

The Transitional Care Coach assists patients and families with transitions post-discharge from hospital stays, nursing homes, ER visits, or observation stays. Responsibilities include conducting comprehensive assessments—covering Social Determinants of Health and potential caregiver burnout. The coach offers personalized support and connects individuals to community resources to ensure effective health management and continuity of care.

Key Responsibilities:

• Provide one-on-one coaching to patients and caregivers to enhance their understanding and management of health conditions post-discharge.
• Conduct comprehensive assessments, including Social Determinants of Health, to identify patients’ strengths and barriers to successful transition.
• Conduct caregiver assessments to identify signs of potential burnout and provide necessary support and interventions.
• Develop, implement, and monitor transitional care plans tailored to meet the individual needs of each patient.
• Educate patients and families about their conditions, medications, lifestyle changes, and the importance of adhering to follow-up appointments.
• Link patients and caregivers to appropriate community resources, such as food banks, housing assistance, caregiver support groups, and counseling services, to address identified needs.
• Facilitate communication between patients, caregivers, and healthcare teams to ensure all parties are informed and aligned on the care plan.
• Coordinate the delivery of services and referrals to support transition needs, such as home health services and social services.
• Monitor patients’ progress post-discharge, addressing complications proactively and providing timely interventions.
• Document and report patient and caregiver interactions, interventions, and outcomes in compliance with organizational and regulatory standards.
• Report instances of abuse, neglect, or exploitation of older adults as required by Ohio law and program guidelines.
• Collaborate with healthcare providers to improve practices and protocols related to transitional care.
• Most assessments are conducted over the phone, but you must have the ability and willingness to travel to all county service areas, including Cuyahoga, Lorain, Geauga, Lake, and Medina counties, to perform in-person assessments when required by member tier levels.

Qualifications:

• Bachelor’s degree in Nursing, Social Work, or Licensed Practical Nursing Certification.
• Valid professional license or certification in a relevant field RN, LSW, LISW, LISW-S, or LPN in the state of Ohio.
• At least 1 years of experience in healthcare coaching, case management, or a related field.
• Demonstrated knowledge of transitional care practices, Social Determinants of Health, caregiver burnout, patient education, and community resources.
• Strong communication, motivational interviewing, and interpersonal skills.
• Ability to work effectively both independently and as part of a multidisciplinary team.
• Experience with electronic health records (EHR) and care management documentation systems.
• Possess the ability and willingness to travel within the service areas mentioned.

If you are interested in joining our team of professionals, please forward your resume and a cover letter. 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.