Care Coordinator, Acute SW II- Orlando Health Watson Clinic Lakeland Highlands Hospital-Lakeland, FL

Orlando Health•Lakeland, FL

About The Position

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. Opening Summer 2026 at 4000 Lakeland Highlands Road, Lakeland, FL. The Orlando Health System of Care 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, Central Alabama and Puerto Rico. Collectively, our dedicated team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Join us! Combining the collective strengths of two powerhouse organizations, Orlando Health and the high-quality physicians at Watson Clinic are expanding access to award-winning specialty care for patients in Polk County and beyond. Opening in summer 2026, Orlando Health Watson Clinic Lakeland Highlands Hospital – a state-of-the-art, seven-story, multi-specialty hospital – will serve as a vital 550,000 square-foot healthcare hub offering: 300+ inpatient beds and 69 emergency and observation beds 11 operating rooms and four cardiac interventional suites Dedicated labor and delivery services – including a neonatal intensive care unit (NICU) that will debut shortly after the hospital opens Comprehensive cardiovascular, neurology, and oncology services Advanced surgical procedures Join us in shaping the future of healthcare in Polk County as part of the Orlando Health Watson Clinic Lakeland Highlands Hospital opening team and share in the privilege of saying you were there from the very beginning. Benefits Beyond the Expected 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.

Requirements

Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.
Handle with Care (HWC) Certification required for Behavioral Health Unit.
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.

Responsibilities

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.