Care Coordinator - Wiregrass Ranch Hospital, Wesley Chapel

Care Coordinator – Wiregrass Ranch Hospital, Wesley Chapel

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Site – FMCOH Wiregrass Ranch Hospital
Location – Wesley Chapel, Florida
Position – Care Coordinator
Department – Care Management
Shift – Days

Elevating Healthcare in Wesley Chapel and West Florida, the Orlando Health affiliate Wiregrass Ranch Hospital is poised to revolutionize local healthcare with a five‑story, state‑of‑the‑art, 380,000‑sq‑ft multi‑specialty facility designed for one of Florida’s fastest‑growing communities.

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services, assessing patients’ risk factors and the need for care coordination, clinical utilization management and preventative care services.

• Takes the lead in ensuring continuity and consistency of care across the continuum (inpatient, emergency and ambulatory care) to facilitate integrated delivery across all settings, including comprehensive discharge planning and follow‑up care.
• Develops an effective working relationship with Patient and Family Counselors/Social Workers and UR nurses to engage the patient/family, advocate and problem‑solve, support and enhance functional ability, and ensure an appropriate and timely discharge plan.
• Daily monitors progress toward discharge plans and/or alters plans due to changes in patient condition or family needs, prioritizing patients at highest risk for complications, admission, or readmission.
• Educates patients/families with chronic illness about evidence‑based standards of care, including self‑management strategies.
• Identifies support needs for patients and families, develops action plans, and provides creative guidance in initiating and overcoming self‑management strategies.
• Educates patients and families about the health care system and facilitates relationship building between 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, consensus attainment, and evaluation of treatment outcomes, tracking progress toward care plan goals and revising the plan as indicated.
• Advocates for patients to optimize health care needs, including 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 decision support tools, referral and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement, including identifying strategies that promote population health.
• Ensures patient safety in the performance of job functions, including the implementation of policies, procedures and standards to support the assigned duties.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
• Maintains compliance with all Orlando Health policies and procedures.

Master’s degree from an accredited school of Social Work, Mental Health, Psychology or Marriage and Family Therapy is required.

Handle with Care (HWC) Certification required for Behavioral Health Unit.

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.

• Entry level

• Full‑time

• Other
• Hospitals and Health Care

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