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Clinical Care Coordinator

2 months ago

Orlando, Florida, United States Orlando Health Full time
Position Overview

At Orlando Health Heart and Vascular Institute, we are dedicated to delivering exceptional care through a collaborative approach involving our esteemed cardiologists, surgeons, and cardiovascular specialists. Our team is committed to excellence across 40 specialties, utilizing cutting-edge diagnostic and treatment methodologies.

Our integrated team comprises over 70 medical professionals across 24 locations in Central Florida, including various counties.

As part of Orlando Health, the Heart and Vascular Institute is supported by a vast network of community and specialty hospitals, encompassing more than 4,000 healthcare providers.

Role Summary

The Clinical Care Coordinator works closely with the designated clinical team to pinpoint patients who would significantly benefit from care coordination services. This includes evaluating patients' risk factors and determining the necessity for care coordination, clinical utilization management, and preventive care services.

Key Responsibilities
  • Lead the effort to maintain continuity and consistency of care throughout the healthcare continuum, ensuring integrated service delivery across all settings, including inpatient, emergency, and outpatient care.
  • Establish effective working relationships with Patient and Family Counselors/Social Workers and Utilization Review Nurses to engage patients and families in collaboration, advocacy, and problem-solving, thereby enhancing their functional capabilities and ensuring timely discharge planning.
  • Monitor daily progress towards discharge plans, adjusting them as necessary based on changes in patient conditions and family needs, prioritizing those at the highest risk for complications or readmissions.
  • Provide education to patients and families with chronic conditions regarding evidence-based care standards and self-management strategies.
  • Identify the support needs of patients and their families, develop actionable plans, and offer guidance to facilitate self-management.
  • Educate patients and families about the healthcare system, fostering relationships across various care settings.
  • Ensure patients have access to necessary prescriptions, durable medical equipment (DME), and other identified services.
  • Contribute to team problem-solving through effective communication, collaboration, data collection, and outcome evaluation, including tracking patient progress towards care plan goals.
  • Advocate for patients to optimize their healthcare needs, addressing safety, physical, legal, and financial well-being.
  • Facilitate referrals for patient education on healthcare delivery systems, prescription drug programs, wellness initiatives, community resources, and housing options.
  • Utilize available IT resources to enhance registry reporting and maintain specified patient populations, improving disease outcomes through evidence-based guidelines.
  • Participate in clinical outcome measurement, identifying strategies that promote population health.
  • Ensure patient safety in all job functions by adhering to established policies, procedures, and standards.
  • Maintain regular attendance in accordance with Orlando Health policies and relevant standards.
  • Comply with all Orlando Health policies and procedures.
Qualifications
  • Possess strong analytical and team-building skills, with the ability to prioritize tasks and work independently.
  • Demonstrate knowledge and skills necessary to provide age-appropriate care, understanding growth and development principles.
  • Exhibit awareness of medical/legal issues, patient rights, and compliance with regulatory standards.
Education and Experience
  • Completion of an accredited nursing (RN) education/training program is required.
  • New hires must obtain a Bachelor of Science in Nursing (BSN) within 36 months of placement.
  • Maintain a current RN license in the State of Florida and BLS/healthcare provider certification.
  • A minimum of three years of direct clinical experience is required, with a focus on the relevant patient population.