About Job

Position Summary:

Orlando Health – Care Coordinator SW – Discharge Support

Department: Corporate Care Management

Status: Full Time

Shift: Day (Remote work can be accommodated after min of 90 days of hire)

Title: Care Coordinator, SW II Acute

Summary: Discharge Support, outpatient care management focused. 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.

Forbes has named Orlando Health as one of America's Best-In-State Employers. 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.

“Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.”

Orlando Health proudly embraces and honors the individuality of our team members. By sharing different ideas and perspectives and working together as a team, we are better able to relate to, care for and authentically serve our patients and families who make up the collective populations in our community. So, no matter who you are, what you believe or how you express yourself, you are welcome here.

ORLANDO HEALTH - BENEFITS & PERKS:

Competitive Pay

Evening, nights, and weekend shift differentials offered for qualifying positions.

All Inclusive Benefits (start day one)

Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.

Forbes Recognizes Orlando Health as a Best-In-State Employer

Forbes has named Orlando Health as one of America's Best-In-State Employers for 2021. Orlando Health is the top healthcare organization in the Metro Orlando area to make the prestigious list. "We are proud to be named once again as a best place to work," said Karen Frenier, VP (HR). "This achievement reflects our positive culture and efforts to ensure that all team members feel respected, supported and valued.

Employee-centric

Orlando Health has been selected as one of the “Best Places to Work in Healthcare” by Modern Healthcare.

Responsibilities:

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 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.

Other Related Functions

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

Qualifications:

Education/Training
Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.

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

Experience
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.