Care Coordination Lead - Full Time Days

Orlando Health Melbourne Hospital Care CoordinatorOrlando Health Melbourne Hospital is a comprehensive medical and surgical acute care facility serving the Brevard County Space Coast as a trusted healthcare provider since 2002. Conveniently located in Melbourne, the 119-bed hospital has all private rooms and is uniquely designed for your comfort and a positive patient experience. Our dedicated team of physicians, nurses, clinicians and medical professionals is committed to delivering the highest level of quality and compassionate care. We provide a complete scope of care, with advanced technology and expertise in a number of specialties, including cardiovascular care, digestive health, emergency care, orthopedics and surgical services.As part of our commitment to quality care, we also are a participant in the American College of Cardiology CathPCI Registry® for improved diagnostic cardiac catheterizations and percutaneous coronary interventions for heart patients.ResponsibilitiesTakes 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 Licensed Mental Health Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, and to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.Assists in collaboration with the assigned team to identify patients most likely to benefit from care coordination services to include assessing the patient's risk factors and needs for care coordination, clinical utilization management services, and preventative services.Serves as mentor to care coordination team through guidance, education, and motivation.Daily monitoring of team performance and 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.Develops collaborative relationships with the site patient care administrators, medical staff leadership, managed care contractors, and community leaders.Ensures all patient care activities support established clinical standards of care and comply with various regulatory agencies and consider age specific, developmental, and cultural needs of the patient population served.Promotes and models appropriate professional behavior as described in the Code of Conduct.Demonstrates a passion for service excellence and commitment to "Patient First" goals.Achieves results by developing strategies to manage patient care across the continuum, focusing on high risk, high cost, and problem prone areas to include patient at risk for re-admission.Supports processes for clinical quality/ cost-improvement initiatives, preventing re-hospitalizations.Builds and maintains effective partnership and relationships with other healthcare teams.Conducts regular guidance and collaboration of team members.Embraces, promotes, and communicates change.Facilitates and supports team member involvement in professional and organizational activities.Demonstrates professional accountability by maintaining proficiency in assigned role.Holds self and others accountable to Orlando Health's mission, vision, and values.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.Monitors completion and compliance of discharge assessments.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.Knowledge of hospital and department policies and procedures as well as knowledge of regulatory requirements relevant to the case management/ care coordination department.Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently.Ability to compile, analyze, and interpret data to include the advanced application in spreadsheet generation and the use of graphics, database management, and word processing software.Maintains confidentiality of data and information.Provides direct patient interventions when determined necessary.Maintains level of knowledge of expertise in the leading-edge developments in the field of the profession.Performs other duties as assigned or required.QualificationsGraduate of an approved school of nursing (RN). Required or Master's degree in Social Work (MSW), Mental Health (MHC) or Marriage and Family Therapy (MFT) from an accredited program. Required2 Years Related healthcare experience and/or supervisory experience in the community with an emphasis on the population to be served in the assigned area. RequiredFL RN license required and maintained current if graduated from an approved school of nursing.BLS/Healthcare Provider certification required within 90 days of hire.