Care Coordinator, Social Worker - Care Management

Orlando Health•Orlando, FL

12h•Onsite

About The Position

Orlando Health Winnie Palmer Hospital for Women & Babies is seeking a Care Coordinator, Social Worker II (NICU). This role collaborates with the assigned clinical team to identify patients who would benefit from care coordination services. This includes assessing patients’ risk factors and their need for care coordination, clinical utilization management, and preventative care services. The hospital, located on the downtown Orlando campus, focuses on the unique needs of women and newborns, offering specialized care from gynecological services to high-risk pregnancies and births. It is recognized for nursing excellence and high-quality patient care, and is certified in perinatal care. Welcoming nearly 14,000 babies annually, it boasts one of the largest neonatal intensive care units in the country.

Requirements

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

Nice To Haves

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

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 Care Management Team 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 healthcare 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. Allscripts Care Management, EMR, etc.) 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.
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.