Licensed Clinical Social Worker, Care Coordinator - Pediatrics Specialty Practice Resources - Downtown Orlando

Orlando Health Medical Group Care Coordinator

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. Orlando Health 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 that span Florida's east to west coasts and beyond.

Collectively, our 27,000+ team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve.

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 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

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.

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. 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. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical…