Care Coordinator, Registered Nurse - Adult Congenital Heart Disease, Orlando

About Orlando Health Medical Group

Orlando Health Medical Group is a comprehensive physician group serving patients from across the southeastern United States. With more than 200 practices and 1,200 physicians, the Group has strong representation in over 55 specialties, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant, critical care medicine, as well as more than 30 pediatric subspecialties, women's health, primary care and the largest hospitalist program in Florida.

Orlando Health Medical Group is part of the Orlando Health system of care, which includes 24 award‑winning hospitals and emergency rooms, 9 specialty institutes, 14 urgent care centers, 100+ primary care practices and more than 60 outpatient facilities spanning Florida’s east to west coasts. We honor our 100-year legacy by providing care for more than 142,000 inpatient and 3.9 million outpatient visits each year.

The organization is committed to providing benefits that go beyond the expected, with free educational programs and well‑being services to support you and your family from day one. We offer flexibility wherever possible so you can be present for your passions.

• Medical, Dental, Vision
• 403(b) Retirement Savings Plan
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Paid Time Off (up to 5 weeks to start)
• Life Insurance
• Extended Leave Plan (ELP)
• Family Care (childcare, elder care, pet care)
• Paid Parental Leave
• Pet Insurance
• Car Insurance
• Educational Benefits including tuition reimbursement and monthly payments to help pay down graduated school debt

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services. The role includes assessing patients' risk factors and need for care coordination, clinical utilization management, and preventive care services.

• Takes the lead in ensuring continuity and consistency of care across the continuum— inpatients, emergency, ambulatory care, and outpatient settings—to provide integrated delivery including comprehensive discharge planning in the hospital and follow‑up care as an outpatient.
• Develops an effective working relationship with Patient and Family Counselors/Social Workers and Utilization Review Nurses to engage patients/families, advocate, problem‑solve, and support their functional ability with timely discharge plans.
• Monitors progress toward discharge plans daily, adjusting plans when patient condition or family needs change, with priority on patients at highest risk for complication, admission, or readmission.
• Educates patients and families with chronic illness about evidence‑based care standards and self‑management strategies.
• Identifies support needs for patients and families, develops action plans, and provides guidance in initiating and overcoming self‑management challenges.
• 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 team problem‑solving through communication, collaboration, data collection, consensus building and evaluation of treatment outcomes, tracking progress toward care‑plan goals and revising plans as indicated.
• Advocates for patients to optimize health‑care needs—including safety, physical, and 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 appropriate services.
• Works with available IT resources (e.g., Phytel, Crimson) to facilitate registry reporting and maintain specified patient populations, improving disease outcome measures through evidence‑based guidelines, clinical decision‑support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement, identifying strategies that promote…