Care Coordinator, Social Worker - Pool Per Diem - Day - Corp

Position Summary
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.

Education/Training
Bachelor’s degree in Social Work, Psychology, Sociology, or other related field.
Licensure/Certification
Handle with Care (HWC) Certification required for Behavioral Health Unit.

Experience
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.

Essential Functions
• 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-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. Allscripts Care Management, EMR, etc.) 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 to include the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions to include the implementation of policies, procedures and standards to
support the 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.
Other Related Functions
• 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 though 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.