Care Coordinator, Acute SW II

Position Summary:

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.

Responsibilities:

• Takes the lead in ensuring the continuity and consistency of care, across the continuum (inpatient, emergency and ambulatory care/

• Develops an effective working relationship with the Patient and Family Counselors/ Social Workers and the UR nurses to engage the

• Daily monitoring of progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family

• 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

• 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

• Advocates for patients in order to optimize their health care needs including but not limited to: safety, physical, legal and financial

• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health &

• Works with available IT resources (i.e. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient

• 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

• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state

• Maintains compliance with all Orlando Health policies and procedures.

• Provides clinical treatment interventions under the supervision of licensed Mental Health Therapist, to include facilitating patient’s

• Participates in facilitation of psychosocial support groups.
• Provides mental health education, information consultation and supporting patient and family needs.
• 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

• Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting

• Performs other duties as assigned or required

Qualifications:

Education/Training

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

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.