Care Coordinator, Acute Social Worker IICollaborates 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. 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. 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. Orlando Health Bayfront Hospital is a comprehensive tertiary care facility that has been serving St. Petersburg and the surrounding communities for more than 100 years. It is a 480-bed teaching medical center with nationally recognized care across emergency medicine, cardiology, neurosurgery, orthopedics, women's services, and advanced surgical specialties. The hospital's Level II Trauma Center is the only adult trauma center in Pinellas County and, in partnership with Johns Hopkins All Children's Hospital, is one of Florida's 13 state-certified Level III Regional Perinatal Intensive Care Centers. A commitment to quality has earned the hospital recognition with a USA Today Top Workplaces award for 2025 and an "A" Hospital Safety Grade for Spring 2025 from The Leapfrog Group. Orlando Health Bayfront Hospital 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. As part of the Orlando Health system, Bayfront combines the resources of a leading regional healthcare network with the personalized, community-focused care that has defined the hospital for generations. Our company is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities. Our people are passionate about what they do 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. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.
