Social Worker

Duly Health and Care • Downers Grove, IL

29d • $58,000 - $87,000 • Onsite

About The Position

At Duly Health and Care, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Social Worker- VBC Full-Time - 40 hours per week. Monday-Friday, 8am-5pm Location: Downers Grove, IL

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: EPIC or other EMR systems (preferred)
• Microsoft Office Suite (Excel, Word, PowerPoint)
• 2–3 years of experience in: Care coordination
• Case management
• Quality
• Experience working in value-based care or managed populations preferred

Nice To Haves

• EPIC or other EMR systems (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