Care Coordinator; RN - Arnold Palmer Hospital, Cardiology Outpatient Center - Orlando

Position: Care Coordinator (RN) - Arnold Palmer Hospital, Cardiology Outpatient Center - Downtown Orlando
Position Summary 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, Orlando Health Medical Group has a strong representation in over 55 specialties, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant and 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 ERs, 9 specialty institutes, 14 urgent care centers, 100+ primary care practices and more than 60 outpatient facilities that span Florida's east to west coasts and beyond. Collectively, we honor our 100-year legacy by providing care for more than 142,000 inpatient and 3.9 million outpatient visits each year.

Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions. "Orlando Health Is Your Best Place to Work" is not just something we say, it's our promise to you.

Orlando Health Offers Great NEW Competitive Pay and Great Benefits Package that Includes:
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 & monthly payments to help pay down any graduated school debt

Job 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 preventive care services. Responsibilities 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 Patient and Family Counselors/Social Workers and the Utilization Review 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.
• Monitors progress towards discharge plans daily, need to alter discharge plan due to change in patient condition, and family needs with a priority placed on those patients at highest risk for complication, admission, or 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 toward 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, and legal and financial well-being.
• Refers patients…