Care Coordinator, SW I

Bayfront Health; Saint Petersburg (FL); On-site; USD 42,000 - 64,000; Full time

Job summary

Bayfront Health is seeking a Care Coordinator, SW I to join the Bayfront Health Medical Group. The role focuses on coordinating care across inpatient, emergency, and outpatient settings, leading discharge planning and follow-up, and working with the care management team to optimize patient outcomes.

The position emphasizes patient education on chronic illness, care navigation, and collaboration with healthcare providers to ensure timely access to services and resources.

Qualifications

• Bachelor’s degree in Social Work, Psychology, Sociology, or related field.
• Handle with Care (HWC) Certification.
• One year of direct clinical experience with the target population or a completed internship in healthcare.

Responsibilities

• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency and ambulatory care/outpatient) to ensure integrated delivery and comprehensive discharge planning and follow-up care.
• Develops an effective working relationship with the Care Management Team to engage the patient/family to collaborate, advocate and problem solve, supporting and enhancing functional ability and timely discharge planning.
• Daily monitoring of progress toward discharge plans and adjusting plans as needed based on patient condition or family needs for high-risk patients.
• Educates patients/families with chronic illness about evidence-based standards of care including self-management strategies.
• Identifies support needs for patients and families, develops action plans, and provides guidance to initiate and sustain self-management.
• Educates patients and families about the health care system and facilitates relationship building across settings.
• Ensures patients have access to prescriptions, DME, and other services.
• Participates in clinical outcome measurement and population health strategies.
• Advocates for patients to optimize health care needs including safety, financial, and legal well-being.
• References education regarding healthcare delivery and reimbursement, prescription drug programs, and community services.
• Works with IT resources to facilitate registry reporting and maintenance of patient populations to improve disease outcomes.

Skills

Clinical experience

Education

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

Handle with Care Certification

Job description

Position Summary

Overview:Title: Care Coordinator, SW ISite: Bayfront Health Medical GroupLocation: Family Medical 7th St SouthDepartment: Bayfront Health MedicalHours: Full-Time | Day Shift

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.

About the organization: Bayfront Medical Group is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico. As part of Orlando Health’s extensive network of comprehensive healthcare services, Bayfront Medical Group is committed to providing easy access to integrated care. Our expansive range of practices offer multiple community locations and convenient appointment options, ensuring patients have seamless access to high‑quality, comprehensive care.Orlando Health is one of Florida’s most respected healthcare systems, known for our unwavering commitment to excellence, patient care, and employee satisfaction. Collectively, our dedicated teams honor a legacy of over 100 years by providing professional and compassionate care to the patients, families and communities we serve.As part of the Bayfront Medical Group, you’ll join a nationally recognized organization that values your work, supports your growth, and provides competitive benefits starting your very first day. Our benefits go beyond the expected, with FREE career-growing education programs, and well-being services to support you and your family through every stage of life. We believe our team is our greatest strength, which is why we offer a culture rooted in compassion, teamwork and flexibility - so that you can be present for your passions. “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.

Why Orlando Health is your best place to work:

Education & Career Growth Assistance Comprehensive Health & Wellness coverage and resources Financial & Retirement Planning with Company Match Excellent Company Culture and Work–Life Balance Family & Pet Support

..and more!

Responsibilities

Responsibilites:

• 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 andevaluating 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.

Qualifications

Minimum Qualifications:

• Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.
• 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.