Care Coordinator, Acute SW II

Orlando Health•Orlando, FL

About The Position

The Care Coordinator, Acute SW II works with the assigned clinical team to identify patients who are most likely to benefit from care coordination. The role assesses patient risk factors and needs for care coordination, clinical utilization management, and preventive care services. The Care Coordinator supports continuity and consistency of care across inpatient, emergency, and ambulatory or outpatient settings. This includes coordinating discharge planning and follow-up care, monitoring progress and adapting plans when patient conditions or family needs change, and prioritizing patients at highest risk of complications, admission, or readmission. The role also educates and advocates for patients and families, connects them with prescriptions, equipment, community resources, and other services, and contributes to team problem-solving and population-health outcomes.

Requirements

Master’s degree from an accredited school of 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. Successful completion of a master’s-level internship within the population served may substitute for the two years of experience.
Handle with Care (HWC) Certification is required for the Behavioral Health Unit.

Responsibilities

Lead efforts to ensure continuity and consistency of care across inpatient, emergency, and ambulatory or outpatient settings, including comprehensive hospital discharge planning and outpatient follow-up care.
Work with Patient and Family Counselors/Social Workers and utilization review nurses to engage patients and families, support collaboration and advocacy, and develop appropriate, timely discharge plans.
Monitor progress toward discharge plans daily and revise plans in response to changes in patient condition or family needs, prioritizing patients at high risk for complications, admission, or readmission.
Educate patients and families about chronic illness, evidence-based standards of care, and self-management strategies.
Identify patient and family support needs, develop action plans, and provide guidance to help patients initiate and sustain self-management strategies.
Educate patients and families about the healthcare 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 needed.
Advocate for patients’ healthcare needs, including safety, physical, legal, and financial well-being.
Refer patients to relevant education and resources, including healthcare delivery and reimbursement information, prescription drug programs, health and wellness programs, community agencies, public and private organizations, housing options, and other services.
Use available IT resources, including Phytel and Crimson, to support registry reporting and maintenance for specified patient populations and improve disease outcomes through evidence-based guidelines, clinical decision-support tools, referral and test tracking, and preventive-care reminders.
Participate in clinical outcome measurement and identify strategies that promote population health.
Promote patient safety by implementing applicable policies, procedures, and standards while performing assigned duties.
Maintain reasonably regular and punctual attendance in accordance with applicable policies and standards.
Comply with Orlando Health policies and procedures.