Care Coordinator, Acute Social Worker II - Orlando Health Bayfront Hospital - St Petersburg, Florida

Position Summary

Site: Orlando Health Bayfront Hospital – St. Petersburg, FloridaPosition: Care Coordinator, Acute Social Worker IISchedule: PRN

 

About Orlando Health Bayfront HospitalOrlando Health Bayfront Hospital is a comprehensive tertiary care facility that has been serving St. Petersburg and the surrounding communities for more than 100 years. A teaching medical center, the 480-bed hospital’s areas of expertise include heart and vascular, digestive health, orthopedics, surgical services, robotic surgery, rehabilitation, neurosciences, maternity care, emergency services and trauma care. The hospital’s Level II Trauma Center is the only adult trauma center in Pinellas County. Home to the Center for Women and Babies, the hospital offers full obstetrical services, and, in partnership with Johns Hopkins All Children’s Hospital, is one of Florida’s 13 state-certified Level III Regional Perinatal Intensive Care Centers. A commitment to quality has earned the hospital recognition with a USA Today Top Workplaces award for 2025 and an “A” Hospital Safety Grade for Spring 2025 from The Leapfrog Group.

Orlando Health Bayfront Hospital is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico. Collectively, our dedicated team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve.

Why Join Orlando Health Bayfront Hospital?

• 2025 USA Today Top Workplace – Join a nationally recognized team that prioritizes employee satisfaction and growth.

• Spring 2025 Leapfrog Grade “A” for Hospital Safety – Your work contributes to a culture of excellence and accountability.

• Member of the Orlando Health System – Enjoy long-term career growth and a supportive network across Central Florida.

• Day-One Benefits – Including FREE education programs, wellness resources, and mental health support.

• Dream Location – Work just steps away from the white-sand beaches and thriving downtown of St. Petersburg.

Job Summary

The Social Worker II 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.

Responsibilities

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, housin