Care Coordinator, Social Worker; Per Diem-Weekend Days Job at Orlando Health
Position Summary:
This position 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:
Develops an effective working relationship with the Patient and Family Counselors/ Social Workers and the UR nurses 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.
Qualifications:
Orlando Health Horizon West Hospital, is located about 16 miles southeast of the downtown Orlando Health campus, adjacent to the Orlando Health Emergency Room and Medical Pavilion–Horizon West. As a comprehensive medical and surgical facility, the hospital is designed to meet the growing healthcare needs of the Horizon West community.
This position 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.
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).
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 Patient and Family Counselors/ Social Workers and the UR nurses 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.
Qualifications:
Education/Training
Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required
Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required
Licensure/Certification
None.
Experience
Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of Master’s level internship within the population to be served may substitute the two (2) years of experience.
None.
Experience
Two (2) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Successful completion of Master’s level internship within the population to be served may substitute the two (2) years of experience.
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