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Care Coordinator, Social Worker - Adults

Company: Orlando Health
Location: Orlando
Posted on: March 18, 2023

Job Description:

Position Summary

For over 100 years, Orlando Health Orlando Regional Medical Center (ORMC) has provided the most advanced options available for surgical, medical, rehabilitative, and emergency care, including serving as Central Florida's only Level 1 Trauma Center. Orlando Health ORMC serves as the organization's flagship hospital, meeting the growing healthcare needs of the region.

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.



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.
  • 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.
  • 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.
  • 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

    • Master's degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required. Licensure/Certification:
      • None

        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.

Keywords: Orlando Health, Orlando , Care Coordinator, Social Worker - Adults, Other , Orlando, Florida

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