Care Coordinator, Social Worker - Pool Per Diem - Day - Corp

Orlando Health; Orlando (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Orlando Health is seeking a care coordination specialist to collaborate with the clinical team in identifying patients who will benefit from care coordination services, assessing risk factors, and coordinating clinical utilization management.

The role emphasizes discharge planning across inpatient, emergency, and outpatient settings, patient/family education, and advocacy to support timely and safe transitions in care.

Qualifications

• Bachelor's degree in Social Work, Psychology, Sociology, or related field.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.
• One year of direct clinical experience or completed internship in healthcare.

Responsibilities

• Lead the continuity of care across inpatient, emergency, and ambulatory settings to ensure integrated delivery.
• Develop relationships with the Care Management Team to engage patients and families, advocate and problem-solve.
• Monitor progress toward discharge plans and adjust plan as patient condition or needs change.
• Educate patients/families on evidence-based standards and self-management strategies.
• Identify support needs, create action plans, and guide self-management initiatives.
• Educate patients about the healthcare system and facilitate access to services and programs.
• Ensure access to prescriptions, DME, and other needed services.
• Participate in clinical outcome measurement and safety/compliance initiatives.

Skills

Care coordination

Discharge planning

Patient advocacy

Cross-team collaboration

Education

Bachelor's degree in Social Work, Psychology, Sociology, or related field

Tools

Allscripts Care Management

EMR systems

Job description

Position Summary

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing

Position Summary

Position Summary

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.

Education/Training

Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.

Licensure/Certification

Handle with Care (HWC) Certification required for Behavioral Health Unit.

Experience

One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship

in healthcare.

Essential Functions

• 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 Care Management Team 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. Allscripts Care Management, EMR, etc.) 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.

Other Related Functions


• 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.