Care Coordinator, Social Worker II- Part Time- Sat, Sun, one Weekday

Overview

ORLANDO HEALTH – HEALTH CENTRAL HOSPITAL Located in Ocoee, Florida, Orlando Health – Health Central Hospital is a 252-bed comprehensive medical and surgical acute-care facility that has been serving the residents of west Orange County for more than 70 years. Services range from 24/7 emergency care to cardiovascular and stroke care, neurosciences, oncology, orthopedics, minimally invasive robotic surgery and more. Our hospital has accreditations and designations in many specialty services, including bariatric surgery, spine surgery, stroke, and hip and knee joint replacement.

We also have earned 2024-25 High Performing Hospital ratings in five areas – COPD, diabetes, heart attack, heart failure and hip replacement – from U.S. News & World Report, and 2024 Top Teaching Hospital recognition from The Leapfrog Group. Orlando Health 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.

Collectively, our team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, 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.

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

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.

Other Related Functions

• Provides clinical treatment interventions under the supervision of licensed Mental Health Therapist, to include facilitating patient’s psychosocial adjustment along the continuum of care and transition to next level of care.
• 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…