Care Transitions Clinician

Reports to: Care Transitions Supervisor FLSA Status: Non-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 works together to create opportunities for Ohioans 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 Social Workers (LSWs), Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) 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 72.5 cents per Mileage reimbursement Free parking and so much more... Position Overview: The Care Transitions Clinician provides participant-centered transitional care services to support older adults and their caregivers during care transitions. This role conducts assessments, delivers education and coaching on health conditions, medications, and self-management, and connects participants to appropriate community and agency resources. Job Duties: Conduct in-home visits or telephonic interventions with members recently discharged from inpatient or observation settings. Perform a comprehensive Care Transitions Assessment, within scope of practice, including: Falls Risk Assessment Social Determinants of Health (SDOH) Assessment Medication Reconciliation (RN only) 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: Assess 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. Manage an assigned caseload and 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 RN, LPN, or LSW in the applicable state. Experience in care transitions, care management, home health, population health, or community-based care preferred. Ability to work independently in the field and manage time effectively. Proficiency with electronic health records and documentation systems. Reliable transportation for home visits, if applicable. Ability to travel throughout our five-county region (Cuyahoga, Geauga, Lake, Lorain, and Medina). If you are interested in joining our team of professionals, please complete the application and upload 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.

Created: 2026-03-04