Care Coordinator, Social Worker I - Bayfront Hospital, St. Petersburg, Florida

Position Summary Site : Orlando Health Bayfront Hospital Location : St. Petersburg, Florida Department : Case Management Position : Care Coordinator, Social Worker I About Orlando Health Bayfront Hospital 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 for Spring 2025 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 over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Job Overview 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. 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 Care Management Team 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. Allscripts Care Management, EMR, etc.) 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. 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. Qualifications Education / Training Bachelor’s degree in Social Work, Psychology, Sociology, or other related field. Experience 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.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 Care Management Team 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. Allscripts Care Management, EMR, etc.) 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. 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.

Education / Training Bachelor’s degree in Social Work, Psychology, Sociology, or other related field. Experience 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.