Care Coordinator, Social Worker - Care Management

Orlando Health • Orlando, FL

1d • Onsite

About The Position

Orlando Health Winnie Palmer Hospital for Women & Babies is seeking a Care Coordinator, Social Worker II to join their Care Management Team. This role collaborates with the assigned clinical team to identify patients who would benefit from care coordination services. Responsibilities include assessing patient risk factors, determining the need for care coordination, clinical utilization management, and preventative care services. The hospital, located on the downtown Orlando campus, specializes in women's health and newborn care, offering comprehensive services from gynecological care to high-risk pregnancies. It is recognized for nursing excellence and perinatal care, and boasts one of the largest neonatal intensive care units in the country. The hospital has received numerous accolades, including being named among the 'Best Children’s Hospitals' and recognized on the '100 Top Hospitals®' list.

Requirements

• Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.
• One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship in healthcare.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.

Responsibilities

• Ensures continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory care/outpatient) to ensure integrated delivery across all settings, including facilitation of comprehensive discharge planning and follow-up care.
• 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, including 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, including tracking patient progress towards care plan goals and revising the care plan as indicated.
• Advocates for patients to optimize their healthcare 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, including the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions, including 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.
• 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 through knowledge of the principles of growth and development over the life span.
• Demonstrates awareness of medical/legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level