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Care Coordinator, SW I - APMC Care Management - req5949


Care Coordinator, SW I - APMC Care Management - req5949 - Arnold Palmer Hospital

Orlando Health is one of Floridas most comprehensive private, not-for-profit healthcare systems providing access to nearly two million Central Florida residents and has provided care for more than 4,600 international visitors annually. Our physician practices, diagnostic centers, hospitals and advanced medical treatments and procedures, along with our highly qualified team of medical specialists, have distinguished Orlando Health as a healthcare leader. We are one of Central Floridas largest employers with more than 15,000 employees and nearly 3,000 affiliated physicians supporting our philosophy of providing a continuum of care that revolves around patients needs. As a leading healthcare resource, providing world-class medical care as well as training our future healthcare providers, Orlando Health will continue to foster growth and development throughout the region for generations to come. We are looking for talented individuals to be part of our team.

Position 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 preventative care services.

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 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 decision support tools, referral and test tracking, and preventive medicine reminders.
  • Participates in clinical outcome measurement to include the identification of strategies that promote population health.
  • Ensures patient safety in the performance of job functions to include 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.

Other Related Functions

  • Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.
  • Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span.
  • Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.


Bachelors degree in Social Work from an accredited program.


One (1) year of direct clinical experience with an emphasis on the population to be served in the assigned area or a completed internship in healthcare.

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