<p>Position Summary Orlando Health Advanced Rehabilitation Institute The Orlando Health Advanced Rehabilitation Institute is a world-class provider of specialty rehabilitation services, whether you need inpatient care or support in an outpatient setting. Our compassionate team of physicians and therapists is dedicated to helping you overcome complications related to stroke, brain injuries, spinal injuries, amputations and anything else that affects your quality of life and independence. Click here to learn more about Orlando Health Advanced Rehabilitation Institute Position Overview 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. Location: 1300 Hempel Ave Ocoee, FL 34761 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. Qualifications Education/Training A Master's degree from an accredited graduate program in Social Work. Licensure/Certification Maintains a Florida license (Chapter 491 Florida Statutes) as a Licensed Clinical Social Worker (LCSW). For Home Health, valid Florida driver's license and must be insurable under the Orlando Health insurance carrier's requirements and standards. Experience Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area.</p> <p>Education/Training A Master's degree from an accredited graduate program in Social Work. Licensure/Certification Maintains a Florida license (Chapter 491 Florida Statutes) as a Licensed Clinical Social Worker (LCSW). For Home Health, valid Florida driver's license and must be insurable under the Orlando Health insurance carrier's requirements and standards. Experience Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area.</p> <p>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.</p>