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

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.

Responsibilities

• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory/outpatient) to facilitate integrated delivery, including comprehensive discharge planning and follow-up care.
• Develops effective working relationships with Patient and Family Counselors/Social Workers and UR nurses to engage patients/families, collaborate, advocate, and problem-solve to support functional ability and ensure timely discharge plans.
• Monitors daily progress toward discharge plans, adjusting as needed due to changes in patient condition or family needs, with priority given to high-risk patients.
• Educates patients and families with chronic illness about evidence-based standards of care, including self-management strategies.
• Identifies support needs for patients and families, develops action plans, and provides guidance on self-management strategies.
• Educates patients and families about the healthcare system and facilitates relationship-building between various care settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other identified services.
• Contributes to team problem-solving through communication, collaboration, data collection, consensus-building, and evaluating treatment outcomes, including tracking patient progress and revising care plans as needed.
• Advocates for patients to optimize their healthcare needs, including safety, physical, legal, and financial well-being.
• Refers patients to education on healthcare delivery, reimbursement systems, prescription drug programs, health and wellness programs, community agencies, housing options, and other relevant services.
• Uses IT resources (e.g., Phytel, Crimson) to facilitate registry reporting, maintain patient populations, improve disease outcomes through evidence-based guidelines, and implement clinical decision support tools.
• Participates in clinical outcome measurement and identifies strategies to promote population health.
• Ensures patient safety by adhering to policies, procedures, and standards.
• Maintains regular, punctual attendance consistent with Orlando Health policies and federal, state, and local standards.
• Complies with all Orlando Health policies and procedures.
• Provides clinical treatment interventions under the supervision of a licensed Mental Health Therapist, facilitating psychosocial adjustment and transitions to the next level of care.
• Participates in facilitating psychosocial support groups.
• Provides mental health education, information consultation, and supports patient and family needs.
• Demonstrates analytical and team-building skills, prioritizes tasks, and works independently.
• Applies knowledge of growth and development principles to provide age-appropriate care.
• Demonstrates awareness of medical/legal issues, patient rights, and compliance with regulatory and accrediting agencies.
• Performs 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.

Schedule

Day shift, as needed for case management coverage, including weekend and holiday rotations.

About the Organization

Orlando Health Bayfront Hospital is a comprehensive tertiary care facility serving St. Petersburg and surrounding communities for over 100 years. It is a 480-bed teaching medical center with nationally recognized care in 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. Orlando Health Bayfront Hospital is part of the Orlando Health system, which includes award-winning hospitals, ERs, specialty institutes, urgent care centers, primary care practices, and outpatient facilities across Florida.

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.
• Benefits begin on day one, including career-growing free education programs and well-being services to support employees and their families through every stage of life.