The role you’ll contribute:

The Connected Care Coordinator will function as the key patient advocate and educator for coordination of post-acute care services within AdventHealth (AH) owned hospitals. This person will assist in assessing patients for post-acute care, coordinating the clinical transition to home health and hospice as clinically indicated and into the appropriate post-acute setting. The Coordinator is responsible for maintaining relationships with physicians, post-acute providers, therapists, patients and families.  This Coordinator will be assigned a specific hospital or specialty and is responsible for collaboration with care management, the physicians, and the clinicians to develop a discharge plan requiring post-acute services across AdventHealth  continuum of care. 

The value you’ll bring to the team: 

·    Responsible for conducting a systematic post-acute assessment of the physical, psychosocial and functional aspects of the patient and his/her family and their impact on the outcome potential to determine appropriateness for the Home Health and Hospice care setting.

·    Inform and educate the patient and family about these post-acute settings, balancing the patient/family requests with what is required to provide safe, reliable, ongoing care for the patient.

·    Identify patient/family problems or needs ensuring communication to physician, care management and the clinical team.

·    Assist with coordination of home health care referrals within assigned hospital(s).  May conduct bedside assessment to determine appropriateness of home or hospice care admission and educates patient/family regarding discharge plan and home care and hospice service expectations. 

·    After receiving Referral, assist with Intake process including pre-registration requirements for HHC admission.

·    Maintains comprehensive working knowledge of managed care along with community resources.

·    Completes and submits all documentation in a timely manner according to department policy.

Minimum Qualifications:

• Master’s Degree in social work  
• Minimum two years of post-acute (e.g., home health and/or skilled nursing facility and/or hospice clinical experience) or Care Management in a facility experience
• Experience working with the public and exceptional customer service skills
• Knowledge of medical terminology and the post-acute referral process
• Social Worker
• Valid driver’s license, automobile insurance, safe driving record and reliable transportation