Care Coordinator, Social Worker (PRN)

About the role

Orlando Health Arnold Palmer Hospital for Children Providing compassionate care to the children, teenagers and young adults of Central Florida for more than 30 years, Orlando Health Arnold Palmer Hospital for Children is located on the downtown Orlando campus and includes 156 licensed beds for specialized care for children as well as the Bert Martin’s Champions for Children Emergency Department & Trauma Center, offering trauma care for children as the pediatric site of the Orlando Health ORMC Level One Trauma Center. State-of-the-art pediatric services are provided by a comprehensive staff that includes pediatric subspecialty physicians and a nursing team that is “Magnet” recognized for nursing excellence and high-quality patient care. The hospital also has earned national recognition for 12 consecutive years as a “Best Children’s Hospitals” by U.S. News & World Report and was included, together with Orlando Health ORMC, in the IBM Watson Health 100 Top Hospitals® list for 2021. Arnold Palmer Hospital for Children Care Management Team is seeking a Care Coordinator, Social Worker I. Care Coordinator, Social Worker II 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

• 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 Care Management Team 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.
• Advocates for patients in order to optimize their health care needs including but not limited to: safety, physical, legal and financial well