Care Coordinator, SW I

Bayfront Health•Saint Petersburg, FL

2d•Onsite

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. About the organization:Bayfront Medical Group is part of the Orlando Health system of care, which 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. As part of Orlando Health’s extensive network of comprehensive healthcare services, Bayfront Medical Group is committed to providing easy access to integrated care. Our expansive range of practices offer multiple community locations and convenient appointment options, ensuring patients have seamless access to high‑quality, comprehensive care.Orlando Health is one of Florida’s most respected healthcare systems, known for our unwavering commitment to excellence, patient care, and employee satisfaction. Collectively, our dedicated teams honor a legacy of over 100 years by providing professional and compassionate care to the patients, families and communities we serve.As part of the Bayfront Medical Group, you’ll join a nationally recognized organization that values your work, supports your growth, and provides competitive benefits starting your very first day. Our benefits go beyond the expected, with FREE career-growing education programs, and well-being services to support you and your family through every stage of life. We believe our team is our greatest strength, which is why we offer a culture rooted in compassion, teamwork and flexibility - 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

Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.
Handle with Care (HWC) Certification required for Behavioral Health Unit.
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.

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 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 andevaluating 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.
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.