Social Worker

Duly Health and Care • Downers Grove, IL

3d • Onsite

About The Position

The Social Worker - VBC position is a full-time role requiring 40 hours per week, with a Monday-Friday schedule from 8 am to 5 pm, located in Downers Grove, IL. This role focuses on patient outreach to close care gaps, ensure preventive care compliance, monitor chronic diseases, improve medication adherence, and facilitate appointment completion. The social worker will assess social determinants of health (SDOH), behavioral health concerns, psychosocial needs, and various barriers such as transportation, financial limitations, housing instability, and food insecurity that impact quality performance and care gap closure. They will develop and implement individualized intervention plans, coordinate community resources, and collaborate with a multidisciplinary team to address complex patient needs and improve engagement and outcomes. The role also involves educating patients on health management, supporting patient engagement strategies for quality performance, maintaining detailed documentation, analyzing trends, and assisting in workflow development. Additionally, the social worker will provide education to providers and staff, participate in shared decision-making, support multiple quality initiatives, adapt to evolving program requirements, and act as a subject matter expert on SDOH and patient engagement in value-based care.

Requirements

• Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) – State of Illinois- Required
• Excellent communication and interpersonal skills across interdisciplinary teams
• Ability to assess psychosocial needs and navigate community resources
• Strong organizational and time management skills across multiple facilities
• Ability to prioritize, problem-solve, and escalate appropriately
• Comfort working in a fast-paced, field-based environment
• Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint)
• 2–3 years of experience in care coordination
• 2–3 years of experience in case management
• 2–3 years of experience in quality

Nice To Haves

• EPIC or other EMR systems (preferred)
• Experience working in value-based care or managed populations preferred

Responsibilities

• Conduct patient outreach to support care gap closure, preventive care compliance, chronic disease monitoring, medication adherence, and appointment completion.
• Assess social determinants of health (SDOH), behavioral health concerns, psychosocial needs, transportation barriers, financial limitations, housing instability, food insecurity, and other factors impacting quality performance and care gap closure.
• Develop and implement individualized intervention plans to address barriers preventing patients from completing recommended care and quality measures.
• Coordinate community resources, behavioral health services, social services, transportation assistance, and other support programs to improve patient engagement and outcomes.
• Collaborate with providers, clinic staff, care managers, and operational leadership to develop multidisciplinary solutions for complex patient populations.
• Educate patients on the importance of preventive care, chronic disease management, medication adherence, and quality gap closure to improve long-term health outcomes.
• Support patient engagement strategies designed to improve Stars/HEDIS performance, preventive screening rates, and chronic disease compliance.
• Maintain detailed and accurate documentation of outreach efforts, interventions, patient barriers, resource coordination, and measurable outcomes.
• Analyze patient engagement trends and recurring barriers to identify opportunities for workflow improvement and enhanced quality performance.
• Assist with development and refinement of workflows related to social needs screening, outreach processes, and quality improvement initiatives.
• Provide education and support to providers and clinic staff regarding social barriers impacting patient care and quality outcomes.
• Participate in shared decision-making with providers and leadership to align patient engagement strategies with organizational quality goals.
• Support multiple quality initiatives simultaneously, including preventive care outreach, chronic disease management support, medication adherence, and social barrier mitigation.
• Adapt quickly to evolving quality program requirements, workflow updates, payer expectations, and organizational priorities.
• Act as a subject matter resource regarding SDOH, patient engagement strategies, and psychosocial barriers impacting value-based care performance.
• Support special projects and additional quality improvement initiatives as assigned.

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed