Role OverviewThe 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.
What You Will Do
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, and providing member education on diagnosis-specific red flags and symptoms requiring follow-up, medication understanding and adherence, and review and use of the member’s Personal Health Record.
Why It Might Be a Fit
We are looking for self-motivated and compassionate professionals 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.
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
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