Licensed Clinical Social Worker — Care Coordination Lead

Orlando Health, Inc.; Orlando (FL); On-site; USD 52,000 - 72,000; Full time

Job summary

Orlando Health Medical Group in Orlando, FL, seeks a Licensed Clinical Social Worker to collaborate with clinical teams, assess patients’ risk factors, coordinate care, and support discharge planning across inpatient, emergency, and ambulatory settings.

The role involves developing relationships with patient/family counselors and UR nurses, monitoring progress, educating families on self-management, and advocating for patients within a compliant, patient-centered care model.

Qualifications

• Master’s degree in Social Work (MSW) required.
• Florida Licensed Clinical Social Worker (LCSW) license.
• Minimum 3 years direct clinical experience.
• Valid Florida driver’s license for Home Health duties.
• Experience coordinating care across inpatient, ED, and ambulatory settings.

Responsibilities

• Lead continuity of care across inpatient, ED, and ambulatory settings.
• Develop and maintain working relationships with patient/family counselors, social workers, and UR nurses.
• Monitor discharge plans and adjust as patient condition changes.
• Educate patients and families on evidence-based self-management.
• Identify support needs and develop action plans.
• Facilitate access to prescriptions and DME.
• Contribute to outcomes measurement and care plan revisions.
• Advocate for patients' safety, legal, and financial well-being.

Skills

Analytical skills

Teamwork

Prioritization

Independent work

Care coordination

Education

Master’s degree in Social Work

Tools

Phytel

Crimson

Job description

Orlando Health Medical Group in Orlando, FL, seeks a Licensed Clinical Social Worker to collaborate with clinical teams, assess patients’ risk factors, coordinate care, and support discharge planning across inpatient, emergency, and ambulatory settings.

The role involves developing relationships with patient/family counselors and UR nurses, monitoring progress, educating families on self-management, and advocating for patients within a compliant, patient-centered care model.