About Orlando Health Medical Group
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, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant, critical care medicine, as well as more than 30 pediatric subspecialties, women’s health, primary care and the largest hospitalist program in Florida.
Orlando Health Medical Group is part of the Orlando Health system of care, which includes 24 award‑winning hospitals and ERs, 9 specialty institutes, 14 urgent care centers, 100+ primary care practices and more than 60 outpatient facilities that span Florida’s east to west coasts and beyond. Collectively, we honor our 100‑year legacy by providing care for more than 142,000 inpatient and 3.9 million outpatient visits each year.
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 Is Your Best Place to Work” is not just something we say, it’s our promise to you.
Benefits
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
Job Summary
The Care Coordinator 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 preventive care services.
Essential Functions
Take 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).
Develop an effective working relationship with the Patient and Family Counselors/Social Workers and the Utilization Review 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.
Monitor progress toward discharge plans daily, altering the discharge plan due to changes in patient condition, and family needs with a priority placed on patients at highest risk for complication, admission, or readmission.
Educate patients and families with chronic illness about evidence‑based standards of care to include self‑management strategies.
Identify support needs for patients and their families, develop action plans, and provide creative guidance in initiating and overcoming any self‑management strategies.
Educate patients and families about the health care system and facilitate relationship building between the various settings.
Ensure patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
Contribute 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.
Advocate for patients in order to optimize their health care needs including but not limited to safety, physical, and legal and financial well‑being.
Refer 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.
Work 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.
Participate in clinical outcome measurement to include the identification of strategies that promote population health.
Ensure patient safety in the performance of job functions to include the implementation of policies, procedures, and standards to support assigned duties.
Maintain reasonable regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
Maintain compliance with all Orlando Health policies and procedures.
Other Related Functions
Possess excellent analytical and team building skills, as well as the ability to prioritize and work independently.
Demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served through knowledge of the principles of growth and development over the life span.
Demonstrate awareness of medical/legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies.
Qualifications
Education/Training
Effective July 1, 2024: New hires and team members moved into this job and/or transferring departments must have obtained a Bachelor of Science in Nursing (BSN) degree.
Licensure/Certification
Maintain current license as an RN in the State of Florida.
Maintain current BLS/healthcare provider certification.
Experience
Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area.