Care Coordinator - Social Worker - master's degree

placeOrlando calendar_month12/31/24

Position Summary:

This is for the hospital which is a 285 bed unit. The job is Monday through Friday and may require a rotating weekend day.

Responsibilities:

Position Summary

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. Discharge planning a major part of this role.

Essential Functions

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

Qualifications:

Education/Training

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

Licensure/Certification

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

Experience

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

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