Care Coordinator, Acute SW II - Wiregrass Ranch Hospital, Wesley Chapel, FL

Responsibilities

• 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.
• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency and ambulatory/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 Patient and Family Counselors/Social Workers and UR nurses to engage the patient/family to collaborate, advocate and problem solve, supporting and enhancing functional ability while ensuring an appropriate and timely discharge plan.
• Monitors daily progress toward discharge plans and/or need to alter discharge plan due to changes in patient condition or family needs, prioritizing patients at highest risk for complication, admission or readmission.
• Educates patients/families with chronic illness about evidence‑based standards of care, including self‑management strategies.
• Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming 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, including tracking patient progress toward care plan goals and revising the care plan as indicated.
• Advocates for patients to optimize their health care needs, including safety, physical, legal and financial well‑being.
• Refers patients to education regarding the healthcare 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, including identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions, including implementation of policies, procedures and standards to support 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.
• Provides clinical treatment interventions under the supervision of a 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 support for patient and family needs.

Qualifications

• 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 the two years of experience.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.
• 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 through knowledge of the principles of growth and development over the life span.
• Demonstrates awareness of medical/legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.