Care Coordinator, SW I

About the organization

Bayfront Medical Group 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. As part of Orlando Health’s extensive network of comprehensive healthcare services, Bayfront Medical Group is committed to providing easy access to integrated care. Our expansive range of practices offers multiple community locations and convenient appointment options, ensuring patients have seamless access to high-quality, comprehensive care.

Orlando Health is one of Florida’s most respected healthcare systems, known for an unwavering commitment to excellence, patient care, and employee satisfaction. Collectively, our dedicated teams honor a legacy of over 100 years by providing professional and compassionate care to the patients, families, and communities we serve.

As part of the Bayfront Medical Group, you’ll join a nationally recognized organization that values your work, supports your growth, and provides competitive benefits starting your very first day. Our benefits go beyond the expected, with free career-growing education programs and well-being services to support you and your family through every stage of life. We believe our team is our greatest strength, which is why we offer a culture rooted in compassion, teamwork, and flexibility—so that you can be present for your passions.

Responsibilities

• Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory/outpatient care) 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 the Care Management Team to engage the patient/family to collaborate, advocate, and problem-solve, supporting and enhancing their functional ability while ensuring an appropriate and timely discharge plan.
• Monitors progress toward discharge plans daily and/or alters the discharge plan due to changes in patient condition or family needs, prioritizing patients at highest risk for complications, admission, or readmission.
• Educates patients and families with chronic illness about evidence-based standards of care, including self-management strategies.
• Identifies support needs for patients and their families, develops action plans, and provides creative guidance in initiating and overcoming self-management barriers.
• Educates patients and families about the healthcare system and facilitates relationship-building between various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other identified services.
• Contributes 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 the care plan as indicated.
• Advocates for patients to optimize their healthcare needs, including but not limited to safety, physical, legal, and financial well-being.
• Refers 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.
• Works with available IT resources (e.g., Allscripts Care Management, EMR) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines, clinical decision support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement, including identifying strategies that promote population health.
• Ensures patient safety in the performance of job functions by implementing 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.

Requirements

• Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.
• Handle with Care (HWC) Certification required for Behavioral Health Unit.
• One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship in healthcare.

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.

Schedule

Full-Time | Day Shift