Care Coordinator Social Worker II - Full Time Days

Orlando Health; Orlando (FL); On-site; USD 60,000 - 85,000; Full time

Job summary

Orlando Health Sebastian River Hospital is seeking a skilled Mental Health Social Worker to coordinate care across inpatient, emergency and outpatient settings. You will partner with the care team to plan discharges, support patients and families, and ensure timely access to needed services.

The role emphasizes collaboration, patient advocacy, and adherence to safety and regulatory standards in a busy hospital setting.

Qualifications

• Master’s degree required in Social Work, Mental Health, Psychology or Marriage and Family Therapy.
• Two years of direct clinical experience in the target population preferred.
• Handle with Care (HWC) certification required for Behavioral Health Unit.

Responsibilities

• Lead continuity of care across inpatient, emergency and ambulatory settings to support discharge planning.
• Collaborate with Patient and Family Counselors, Social Workers and UR nurses to engage patients and families.
• Monitor progress toward discharge and adjust plans for high-risk patients.
• Educate patients and families on evidence-based self-management strategies.
• Identify support needs and develop action plans with patients and families.
• Facilitate psychosocial support and education about health care systems and services.
• Coordinate access to prescriptions, DME, and other services as needed.
• Ensure safety and compliance with regulatory and accrediting standards.

Skills

Analytical skills

Team collaboration

Communication skills

Crisis intervention

Education

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

Tools

Phytel

Crimson

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 Sebastian River Hospital

Orlando Health Sebastian River Hospital is a 178-bed comprehensive medical and surgical facility serving the communities along Florida’s Treasure Coast as a trusted healthcare provider for more than 50 years. With the latest technology and a team of skilled healthcare professionals, we are committed to bringing the highest level of expert and compassionate care to the communities we serve.

With a full scope of care, we offer advanced technology and expertise in a number of specialties, including emergency care, heart and vascular care, orthopedics and surgical services. Recognized for high standards, we have earned full hospital and laboratory accreditation from The Joint Commission, as well as advanced certification as a Primary Stroke Center for our high-quality stroke care. As further demonstration of our commitment to quality and safety, we have earned several additional industry recognitions.

Click Here to Learn More About: Sebastian River Hospital

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 clinical team to identify patients most likely to benefit from care coordination services to include assessing patients' risk factors and 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 Patient and Family Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan.
• Daily monitoring of 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.
• Educates patients/ families with chronic illness about evidence-based standards of care to include self-management strategies.
• Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies.
• Educates patients and families about the health care system and facilitates relationship building between the various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
• 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.
• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services, as appropriate.
• Works with available IT resources (i.e. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement to include the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions to include the implementation of policies, procedures and standards to support the assigned duties.
• 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.
• Provides clinical treatment interventions under the supervision of licensed Mental Health Therapist, to include facilitating patient’s psychosocial adjustment along the continuum of care and transition to next level of care.
• Participates in facilitation of psychosocial support groups.
• Provides mental health education, information consultation and supporting patient and family needs.
• Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span.
• Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.
• Performs other duties as assigned or required

Qualifications

Qualifications

• Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.
• Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of Master’s level internship within the population to be served may substitute the two (2) years of experience.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.