Care Coordinator, Acute SW II

Orlando Health•Lakeland, FL

3d•Onsite

About The Position

The Care Coordinator collaborates with the assigned clinical team to identify patients who are most likely to benefit from care coordination, including assessing risk factors and care coordination needs. The role supports continuity and consistency of care across inpatient, emergency, and ambulatory/outpatient settings, including comprehensive discharge planning and outpatient follow-up. This position is for the Orlando Health Watson Clinic Lakeland Highlands Hospital opening team in Lakeland, Florida, with an opening planned for summer 2026. The listed schedule is second shift, 2 p.m. to 10 p.m. The Care Coordinator partners with patients, families, Patient and Family Counselors/Social Workers, utilization review nurses, and other team members to develop and monitor care plans, support self-management, and address barriers to appropriate and timely discharge. The position also provides psychosocial support and mental health education, connects patients with health care and community resources, and contributes to clinical outcome measurement and population health initiatives. The role requires a master’s degree in Social Work, Mental Health, Psychology, or Marriage and Family Therapy, and two years of direct clinical experience focused on the population served. Handle with Care certification is required for the Behavioral Health Unit. Successful completion of a master’s-level internship serving the applicable population may substitute for the experience requirement; the provided posting ends before fully stating this qualification.

Requirements

Master’s degree from an accredited school in Social Work, Mental Health, Psychology, or Marriage and Family Therapy.
Two years of direct clinical experience, with an emphasis on the population served in the assigned area.
Handle with Care (HWC) certification is required for the Behavioral Health Unit.
Successful completion of a master’s-level internship within the population served may substitute for the stated experience requirement; the posting’s sentence is incomplete.
Excellent analytical and team-building skills, with the ability to prioritize and work independently.
Knowledge and skills necessary to provide care appropriate to the ages of patients served, including knowledge of growth and development across the life span.
Awareness of medical/legal issues and patient rights, and ability to comply with regulatory and accrediting standards.

Responsibilities

Lead efforts to ensure continuity and consistency of care across inpatient, emergency, and ambulatory/outpatient settings, including comprehensive hospital discharge planning and outpatient follow-up.
Build effective working relationships with Patient and Family Counselors/Social Workers and utilization review nurses to engage patients and families, collaborate, advocate, solve problems, and support functional ability and timely discharge planning.
Monitor progress toward discharge plans daily and identify when plans need to change due to changes in patient condition or family needs, prioritizing patients at highest risk for complications, admission, or readmission.
Educate patients and families about evidence-based standards of care and self-management strategies for chronic illness.
Identify patient and family support needs, develop action plans, and provide guidance to initiate and overcome barriers to self-management.
Educate patients and families about the health care system and facilitate relationships among care settings.
Ensure patients have access to prescriptions, durable medical equipment, and other identified services.
Contribute to team problem solving through communication, collaboration, data collection, consensus building, and evaluation of treatment options; track progress toward care plan goals and revise plans as indicated.
Advocate for patients’ health care needs, including safety and physical, legal, and financial well-being.
Refer patients to education and resources related to health care delivery and reimbursement, prescription drug programs, health and wellness programs, community agencies, public and private organizations, housing, and other appropriate services.
Use available IT resources, including Phytel and Crimson, to support registry reporting and maintenance for specified patient populations, evidence-based guidelines, clinical decision support, referral and test tracking, and preventive medicine reminders.
Participate in clinical outcome measurement and identify strategies that promote population health.
Promote patient safety by implementing applicable policies, procedures, and standards in job functions.
Maintain reasonably regular and punctual attendance and comply with Orlando Health policies and procedures.
Provide clinical treatment interventions under the supervision of a licensed Mental Health Therapist, including facilitating patients’ psychosocial adjustment along the continuum of care and transition to the next level of care.
Participate in facilitating psychosocial support groups.
Provide mental health education, information, consultation, and support for patient and family needs.
Demonstrate knowledge and skills appropriate to the ages of patients served, including principles of growth and development across the life span.
Maintain awareness of medical/legal issues and patient rights, and comply with regulatory and accrediting standards.
Perform other duties as assigned or required.