Care Coordinator, Acute Social Worker II - Baby Place - Orlando Health Bayfront Hospital - St P

Site Orlando Health Bayfront Hospital
Location St. Petersburg, Florida
Position Care Coordinator, Acute Social Worker II
Department Baby Place
Schedule Full-Time;
Day shift

Orlando Health Bayfront Hospital is a comprehensive tertiary care facility that has been serving St. Petersburg and the surrounding communities for more than 100 years. A teaching medical center, the 480‑bed hospital’s areas of expertise include heart and vascular, digestive health, orthopedics, surgical services, robotic surgery, rehabilitation, neurosciences, maternity care, emergency services and trauma care. The hospital’s Level II Trauma Center is the only adult trauma center in Pinellas County.

Home to the Center for Women and Babies, the hospital offers full obstetrical services, and, in partnership with Johns Hopkins All Children’s Hospital, is one of Florida’s 13 state‑certified Level III Regional Perinatal Intensive Care Centers. A commitment to quality has earned the hospital recognition with a USA Today Top Workplaces award for 2025 and an “A” Hospital Safety Grade from The Leapfrog Group.

Orlando Health Bayfront Hospital 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, Central Alabama and Puerto Rico. Collectively, our dedicated team members honor our 100‑year legacy by providing professional and compassionate care to the patients, families and communities we serve.

The Social Worker II collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services, including 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 of 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 toward 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 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, legal and financial well‑being.
• Refers patients to education regarding the health‑care 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 decision support…