Care Coordination Specialist

BayCare Health System; Tallahassee (FL); On-site; USD 32,000 - 47,000; Full time

Job summary

BayCare Health System seeks a Care Coordination Specialist to join our interdisciplinary team in South Florida. The role focuses on comprehensive care coordination and discharge planning to optimize patients’ clinical and financial outcomes within a value-based care model.

The position involves assessing barriers to transitions of care, coordinating referrals, and linking patients to community resources to support effective post-acute care and avoid readmissions.

Qualifications

• Bachelor's degree in social work, psychology, or healthcare related field OR LPN License.
• Medical Social Work or LPN experience preferred.

Responsibilities

• Function as a key member of an interdisciplinary, value-based care delivery model to optimize clinical, quality, and financial outcomes.
• Provide comprehensive care coordination and discharge planning to ensure appropriate post-acute resource utilization, reduce readmissions, and support risk stratification.
• Identify and address barriers to transitions of care, including social determinants of health, to improve outcomes and reimbursement.
• Coordinate transition of care activities, including referrals, post-acute authorizations if needed, transportation needs, and linkage to community resources.

Education

Bachelor's degree in social work, psychology, or healthcare related field OR LPN License

Job description

At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that’s built on a foundation of trust, dignity, respect, responsibility and clinical excellence.

The Care Coordination Specialist Will

• Function as a key member of an interdisciplinary, value-based care delivery model, collaborating with patients, nursing, physicians, advanced practitioners, caregivers, and community partners to optimize clinical, quality, and financial outcomes.
• Provide comprehensive care coordination and interdisciplinary discharge planning processes for patients ensuring appropriate utilization of post-acute resources, reduce avoidable readmissions, and support accurate risk stratification. Integrates clinical, social, and economic determinants of health into individualized care planning, ensuring alignment with patient acuity, developmental stage, and payer requirements.
• Proactively identify and address barriers impacting transitions of care, including social determinants of health (SDOH), to enhance patient outcomes and support appropriate risk adjustment and reimbursement optimization.
• Perform transition of care management, including timely coordination of services, facilitation of medically necessary referrals, initiating post-acute authorizations if applicable, assisting with transportation needs, and effective linkage to community-based resources to ensure continuum of care.
• Apply strong organizational and operational management skills to coordinate multiple high-impact workflows, supporting compliance with regulatory requirements, efficient length of stay management, and improved performance in value-based reimbursement models.

Position Details

• Location: South Florida Baptist Hospital - Plant City, FL
• Status: PRN, As Needed.
• Schedule: Days will vary - 8:00 AM - 4:30 PM
• Weekend Requirement: Occasional
• On Call: No

Education And/or Licensure

• Bachelor's degree in social work, psychology, or healthcare related field OR LPN License.

Experience

• Medical Social Work or LPN experience preferred

Benefits

401k match and additional yearly contribution

Community discounts and more

Equal Opportunity Employer Veterans/Disabled