Care Coordinator, Acute SW II

CARE COORDINATOR, ACUTE SW II

Organization: Orlando Regional Medical Center (ORMC)

Employment Type: Full-Time

Shift: 8:00am - 4:30pm

Position Summary: Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services, including assessing patients’ risk factors and the need for care coordination, clinical utilization management, and preventative care services.

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.

Essential Functions:

• Takes the lead in ensuring 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 (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 toward 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 toward 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 health care 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. Phytel, Crimson) 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.

Compliance: Maintains compliance with all Orlando Health policies and procedures.