Care Coordination Lead - Full Time Days

Orlando Health, Inc.; Orlando (FL); On-site; USD 80,000 - 100,000; Full time

Job summary

Orlando Health Melbourne Hospital is seeking a skilled care coordination leader to ensure seamless patient care across inpatient, emergency, and outpatient settings. You will collaborate with Licensed Mental Health Counselors, Social Workers, and UR nurses to develop and implement discharge plans, assess risk, and optimize patient outcomes while upholding quality standards and regulatory compliance.

Strong analytical and mentoring abilities are essential to drive performance and foster a culture

Qualifications

• RN license active in Florida.
• Master’s degree in Social Work, Mental Health, or Marriage and Family Therapy from an accredited program.
• Minimum 2 years of related healthcare experience.
• BLS/Healthcare Provider certification within 90 days of hire.

Responsibilities

• Lead continuity of care across inpatient, emergency, and ambulatory settings.
• Collaborate with care coordination team including LCSWs and UR nurses to plan discharge and support patients.
• Identify patients who benefit from care coordination and manage discharge planning.
• Mentor care coordination team and monitor performance toward discharge goals.
• Ensure adherence to clinical standards and regulatory requirements.

Education

RN license

Master’s degree in Social Work, Mental Health, or Marriage and Family Therapy

Job description

Position Summary

"Orlando Health Is Your Best Place to Work" is not just something we say, it’s our promise to you.

About Orlando Health Melbourne Hospital

Orlando Health Melbourne Hospital is a comprehensive medical and surgical acute care facility serving the Brevard County Space Coast as a trusted healthcare provider since 2002. Conveniently located in Melbourne, the 119-bed hospital has all private rooms and is uniquely designed for your comfort and a positive patient experience. Our dedicated team of physicians, nurses, clinicians and medical professionals is committed to delivering the highest level of quality and compassionate care.

We provide a complete scope of care, with advanced technology and expertise in a number of specialties, including cardiovascular care, digestive health, emergency care, orthopedics and surgical services. Recognized for high standards, we have earned full hospital and laboratory accreditation from The Joint Commission, and we are the first hospital in Brevard County to receive spine surgery certification for our specialized spine program. The Joint Commission’s Gold Seal of Approval® distinguishes healthcare organizations and programs that exemplify their commitment to using best practices to improve safety and quality for their patients, staff and community. As part of our commitment to quality care, we also are a participant in the American College of Cardiology CathPCI Registry® for improved diagnostic cardiac catheterizations and percutaneous coronary interventions for heart patients.

WHY ORLANDO HEALTH?

Competitive Pay

Evening, nights, and weekend shift differentials offered for qualifying positions.

All Inclusive Benefits (Starting On Day One)

Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.

Employee-centric

Orlando Health has been selected as one of the “Top Places to Work in Healthcare” by Becker’s Healthcare.

Company is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview

Collaborates with the assigned care coordination team to include clinical support, guidance, and educational direction while also identifying patients most likely to benefit from care coordination services to include assessing patients' risk factors, the need for care coordination, clinical utilization management, and preventative care services.

Our people are passionate about what they do, the product they sell, and the customers they serve. If you're looking for an opportunity to be a part of a work family that values collaboration, innovation and dedication, we're the right company for you.

Section 1557 Non-Discrimination

The Office for Civil Rights (OCR) enforces Section 1557 of the Affordable Care Act (Section 1557), which prohibits discrimination on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, gender identity, and sex characteristics), in covered health programs or activities. 42 U.S.C. 18116.

Responsibilities

What you will do

• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory care/outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
• Develops an effective working relationship with the Licensed Mental Health Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, and to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
• Assists in collaboration with the assigned team to identify patients most likely to benefit from care coordination services to include assessing the patient's risk factors and needs for care coordination, clinical utilization management services, and preventative services.
• Serves as mentor to care coordination team through guidance, education, and motivation.
• Daily monitoring of team performance and progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family needs, with a priority placed on those patients at highest risk for complication/ admission/ readmission.
• Develops collaborative relationships with the site patient care administrators, medical staff leadership, managed care contractors, and community leaders.
• Ensures all patient care activities support established clinical standards of care and comply with various regulatory agencies and consider age specific, developmental, and cultural needs of the patient population served.
• Promotes and models appropriate professional behavior as described in the Code of Conduct.
• Demonstrates a passion for service excellence and commitment to “Patient First” goals.
• Achieves results by developing strategies to manage patient care across the continuum, focusing on high risk, high cost, and problem prone areas to include patient at risk for re-admission.
• Supports processes for clinical quality/ cost-improvement initiatives, preventing re-hospitalizations.
• Builds and maintains effective partnership and relationships with other healthcare teams.
• Conducts regular guidance and collaboration of team members.
• Embraces, promotes, and communicates change.
• Facilitates and supports team member involvement in professional and organizational activities.
• Demonstrates professional accountability by maintaining proficiency in assigned role.
• Holds self and others accountable to Orlando Health’s mission, vision, and values.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus, and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals, and revising the care plan as indicated.
• Advocates for patients in order to optimize their health care needs including but not limited to safety, physical, legal, and financial well-being.
• Monitors completion and compliance of discharge assessments.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
• Knowledge of hospital and department policies and procedures as well as knowledge of regulatory requirements relevant to the case management/ care coordination department.
• Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.
• Ability to compile, analyze, and interpret data to include the advanced application in spreadsheet generation and the use of graphics, database management, and word processing software.
• Maintains confidentiality of data and information.
• Provides direct patient interventions when determined necessary.
• Maintains level of knowledge of expertise in the leading-edge developments in the field of the profession.
• Performs other duties as assigned or required.

Qualifications

• Graduate of an approved school of nursing (RN). Required or
• Master’s degree in Social Work (MSW), Mental Health (MHC) or Marriage and Family Therapy (MFT) from an accredited program. Required
• 2 Years Related healthcare experience and/or supervisory experience in the community with an emphasis on the population to be served in the assigned area. Required
• FL RN license required and maintained current if graduated from an approved school of nursing. BLS/Healthcare Provider certification required within 90 days of hire. Required