Location:Orion Building -6630 Orion DriveFort Myers FL 33912
Department: Administration Services - CCT
Work Type: Full Time, Salaried
Shift: Shift 1/ to
Minimum to Midpoint Pay Rate:$57,345.60 - $74,547.20 / Annual
Summary
Care Coordination & Behavioral Health Referral
- Assess patients psychosocial, emotional, and social needs.
- Identify patients requiring behavioral health support and coordinate referrals to specialized behavioral health teams.
- Connect patients and families with community resources, post-acute care services, and support systems.
- Collaborate with care managers, interdisciplinary teams, and community providers to ensure continuity of care.
- Assist patients and families with navigating insurance, placement, and post-discharge resources.
Patient Advocacy
- Advocate for patients by facilitating communication between patients, families, physicians, and healthcare teams.
- Promote patient self-determination by providing information about care options and supporting participation in care planning.
- Support patients and families in understanding advanced directives and treatment choices.
Transition & Discharge Planning
- Participate in care planning to ensure safe and timely discharges.
- Assess patients capacity for self-care and the availability of caregivers.
- Provide education and resources to support patient goals and preferences.
- Monitor high-risk patients and coordinate interventions to prevent readmissions.
- Obtain approvals for post-acute services and provide patients/families with options.
Documentation & Compliance
- Maintain accurate and timely documentation of assessments, referrals, care conferences, discharge plans, and interventions in the EMR.
- Track patient outcomes and care coordination metrics as required.
Team Collaboration & Professional Development
- Work collaboratively with multidisciplinary teams to meet patient needs.
- Serve as a positive team member, assisting colleagues and supporting workflow.
- Participate in mentoring or onboarding of new staff or MSW students when applicable.
- Maintain professional boundaries and adhere to organizational policies.
RequirementsEducation:
Masters Degree in Social Work required.
Experience:
Minimum of 1-year clinical experience in medical or healthcare setting.
License:
Not required
Certification:
Not required
Other:
Communication and interpersonal skills, basic computer, analytical, grammar and spelling skills. Ability to effectively multi-task and prioritize responsibilities.
US:FL:Fort Myers
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