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, Florida Medical Clinic Orlando Health Wiregrass Ranch Hospital is poised to revolutionize healthcare in Wesley Chapel and the broader West Florida region. This five-story, state-of-the-art multi-specialty hospital spans 380,000 square feet, purpose-built to serve one of Florida’s fastest-growing communities with exceptional, outcomes-focused care.

Designed for Excellence:

• Opening with 102 beds, expandable to 300 beds at full build-out
• 9 advanced operating rooms, including a hybrid OR with real-time imaging capabilities
• Comprehensive services in cardiology, neurology, oncology, surgery, and more

From life-saving procedures to advanced diagnostics, this facility is engineered to meet the evolving needs of our community with precision and compassion.

Job 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

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

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

Experience
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