Job Description

Position Summary:

Orlando Health Dr. P. Phillips proudly holds recognition as a

"Best Regional Hospital"

by U.S. News & World Report and selected as one of the "Best Places to Work in Healthcare" by Modern Healthcare. We are an award-winning, full-service medical/surgical facility that has been serving the residents of southwest Orange County and Orlando's growing tourist population since 1985. With a highly qualified team of nurses, support staff and physician specialists, our 285-bed facility provides combined expertise and advanced technology in numerous areas of specialty, including diagnostic imaging, cardiovascular care, orthopedic care, surgical services and emergency medicine.

In 2025, Dr. P. Phillips Hospital opened the

onsite Team Member Wellness Center

, designed to support employee health and well-being. The center features a state-of-the-art fitness facility, a dedicated tranquility space, and wellness activities - making it easy to recharge and get your workout in before or after your shift.

"Orlando Health Is Your Best Place to Work" is not just something we say, it's our

promise to you."


Responsibilities:

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 thebpatient/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 dutie
Qualifications:

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