Integrated Care Coordination & Discharge Specialist

Orlando Health, Inc.; Orlando (FL); On-site; USD 52,000 - 80,000; Full time

Job summary

Orlando Health, Inc. in Orlando, FL is seeking a qualified social work professional to provide care coordination within the behavioral health unit.

You will collaborate with clinical teams to assess risk factors, coordinate discharge planning, and support patients and families through transitions. The role emphasizes patient advocacy, education, and the use of IT tools to track outcomes and ensure follow-up.

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

Responsibilities

• Lead in ensuring continuity of care across inpatient, emergency and ambulatory settings with integrated discharge planning.
• Engage patients and families, collaborating with social workers and UR nurses to support and problem solve.
• Monitor progress toward discharge plans and adjust plans as patient condition changes.
• Educate patients and families about evidence-based care and self-management strategies.
• Identify support needs and develop action plans to overcome barriers to self-management.
• Facilitate access to prescriptions, DME and other services as identified.
• Contribute to outcomes tracking and quality improvement through data collection and team collaboration.

Skills

Care coordination

Team collaboration

Analytical skills

Education

Master’s degree in Social Work or related field

Tools

Phytel

Crimson

Job description

Orlando Health, Inc. in Orlando, FL is seeking a qualified social work professional to provide care coordination within the behavioral health unit.

You will collaborate with clinical teams to assess risk factors, coordinate discharge planning, and support patients and families through transitions. The role emphasizes patient advocacy, education, and the use of IT tools to track outcomes and ensure follow-up.