Care Coordinator, SW I

About the Role

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.

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 spanning Florida’s east to west coasts, Central Alabama, and Puerto Rico. As part of Orlando Health’s extensive network, Bayfront Medical Group is committed to providing easy access to integrated care through multiple community locations and convenient appointment options, ensuring 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. With a legacy of over 100 years, we provide professional and compassionate care to patients, families, and communities. As part of Bayfront Medical Group, you’ll join a nationally recognized organization that values your work, supports your growth, and offers competitive benefits from your very first day.

Benefits

• Free career-growing education programs
• 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

Responsibilities

• Ensures 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 the Care Management Team to engage patients and families, collaborate, advocate, and problem-solve to support functional ability and timely discharge planning.
• Monitors progress toward discharge plans daily, prioritizing high-risk patients for complications, admission, or readmission, and adjusts plans as needed.
• Educates patients and families with chronic illnesses about evidence-based care standards, 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 across 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 services as appropriate.
• Uses IT resources (e.g., Allscripts Care Management, EMR) to facilitate registry reporting, maintain patient populations, improve disease outcome measures 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.
• Maintains compliance with all Orlando Health policies and procedures.

Qualifications

• Bachelor’s degree in Social Work, Psychology, Sociology, or a 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.