Care Coordinator / Acute Social Worker II - PRN Pool - Bayfront Hospital - St Petersburg

Location: St. Petersburg, FL (On Site)

Position Type: PRN Pool

Schedule

• Day shift, as needed for case management coverage
• Includes weekend and holiday rotations

Responsibilities

• Collaborate 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.
• Lead efforts to ensure continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory/outpatient care) to facilitate integrated delivery across all settings, including comprehensive discharge planning and follow-up care.
• Develop effective working relationships with Patient and Family Counselors/Social Workers and UR nurses to engage patients/families in collaboration, advocacy, and problem-solving to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
• Monitor daily progress toward discharge plans and/or adjust plans due to changes in patient condition or family needs, prioritizing patients at highest risk for complications, admission, or readmission.
• Educate patients and families with chronic illnesses about evidence-based standards of care, including self-management strategies.
• Identify support needs for patients and their families, develop action plans, and provide creative guidance in initiating and overcoming self-management barriers.
• Educate patients and families about the healthcare system and facilitate relationship-building between various care settings.
• Ensure patients have access to prescriptions, durable medical equipment (DME), and other identified services.
• Contribute to problem-solving within the team through communication, collaboration, data collection, consensus-building, and evaluating outcomes of treatment options, including tracking patient progress toward care plan goals and revising plans as needed.
• Advocate for patients to optimize their healthcare needs, including safety, physical, legal, and financial well-being.
• Refer patients to education regarding healthcare delivery and reimbursement systems, prescription drug programs, health and wellness programs, community agencies, public and private organizations, housing options, and other services as appropriate.
• Utilize IT resources (e.g., Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations, improving disease outcome measures through evidence-based guidelines, clinical decision support tools, referral and test tracking, and preventive medicine reminders.
• Participate in clinical outcome measurement, including identifying strategies that promote population health.
• Ensure patient safety in job performance by implementing policies, procedures, and standards.
• Maintain regular, punctual attendance consistent with Orlando Health policies, ADA, FMLA, and other federal, state, and local standards.
• Maintain compliance with all Orlando Health policies and procedures.
• Provide clinical treatment interventions under the supervision of a licensed Mental Health Therapist, facilitating patients' psychosocial adjustment along the continuum of care and transition to the next level of care.
• Participate in facilitating psychosocial support groups.
• Provide mental health education, information consultation, and support for patient and family needs.
• Demonstrate excellent analytical and team-building skills, as well as the ability to prioritize and work independently.
• Demonstrate knowledge and skills necessary to provide care appropriate to the age of patients served, including understanding principles of growth and development over the lifespan.
• Demonstrate awareness of medical/legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies.
• Perform other duties as assigned or required.

Requirements

• Master’s degree from an accredited school of Social Work, Mental Health, Psychology, or Marriage and Family Therapy is required.
• Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of a Master’s level internship within the population to be served may substitute for the two (2) years of experience.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.

About the Organization

Orlando Health Bayfront Hospital is a comprehensive tertiary care facility that has been serving St. Petersburg and the surrounding communities for more than 100 years. It is a 480-bed teaching medical center with nationally recognized care across emergency medicine, cardiology, neurosurgery, orthopedics, women’s services, and advanced surgical specialties. The hospital’s Level II Trauma Center is the only adult trauma center in Pinellas County and, in partnership with Johns Hopkins All Children’s Hospital, is one of Florida’s 13 state-certified Level III Regional Perinatal Intensive Care Centers. A commitment to quality has earned the hospital recognition with a USA Today Top Workplaces award for 2025 and an “A” Hospital Safety Grade for Spring 2025 from The Leapfrog Group.

Orlando Health Bayfront Hospital 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. As part of the Orlando Health system, Bayfront combines the resources of a leading regional healthcare network with the personalized, community-focused care that has defined the hospital for generations.

Benefits

• Education and Career Growth Assistance
• Comprehensive Health and Wellness coverage and resources
• Financial and Retirement Planning with Company Match
• Excellent Company Culture and Work-Life Balance
• Family and Pet Support and more

Orlando Health is committed to providing 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. Benefits begin on day one and offer flexibility wherever possible.