Duly Health and Care-posted about 16 hours ago
$62,000 - $94,000/Yr
Full-time • Entry Level
Remote • Downers Grove, IL
5,001-10,000 employees

The Specialty Care Coordinator is a critical member of our integrated specialty care team consisting of nurses, dietitians, pharmacists, care coordinators, and physicians. The Specialty Care Coordinator will be working in collaboration with the specialty care team, healthcare professionals, patients, and families to provide ongoing support and communication for patients with complex care, including chronic kidney disease (CKD), End-Stage Renal Disease (ESRD), congestive heart failure (CHF), and other complex cardiac conditions. Specialty Care Coordinators will support Specialty RN Care Managers, escalating clinical concerns and complex care needs as appropriate. This position does not require RN licensure, but must have strong clinical acumen, attention to detail, and the ability to navigate complex care environments. The primary focus of the role will be to improve patient outcomes, including delaying disease progression, avoiding unnecessary inpatient and emergency department utilization, supporting patient self-management, and contributing to better long-term outcomes. Specialty Care coordinators will be supported by predictive data to identify the highest risk patients and high-touch care workflows that integrates with Duly’s primary and specialty care providers. While primarily conducted via telecommunication, this role may necessitate potential for periodic in-person collaboration with the specialty care team. This individual acts as a single point-of-contact to coordinate resources along the care delivery spectrum, identify gaps, and provide proactive follow-up. The Specialty Care Coordinator is responsible for making sure the patient’s care at various locations is connected and there are no gaps in care or communication.

  • Conducts structured telephonic outreach to high-risk and complex patients to understand their clinical needs and connect them with appropriate resources.
  • Performs outbound calls to providers to make appointments for patients or follow up on care and answers inbound calls from patients, providers, and other resources.
  • Maintain a caseload of assigned patients, using risk stratification to prioritize care
  • Maintain proactive communication with Physicians, APPs, PCP offices and other clinical partners to ensure timely clinical escalation, alignment with treatment plans, and coordination of services
  • Follows up with patients to ensure their needs are met and schedules future check-ins. Notifies patients of location and appointment times as needed.
  • Completes / supports completion of initial assessments and timely follow-ups addressing current symptoms, medication adherence, and functional / psychosocial status, and
  • Assess home safety and social determinants of health (SDOH) barriers, including transportation, food insecurity, housing instability, and caregiver support; escalate resource needs where appropriate.
  • Perform patient health assessments and advance care planning / follow-up care as needed
  • Monitor for signs of worsening conditions or gaps in care, and escalate as needed
  • Manage patients during periods of transitions of care to facilitate effective transitions and minimize avoidable readmissions, including medication reconciliation, red-flag symptom screening, and appointment scheduling
  • Provide patient and caregiver education and promote evidence-based self-management strategies
  • Review and document patient updates and progress
  • Analyze data collected from the predictive modeling tools to identify eligible patients for care management
  • Proficient in current Case Management Standards
  • Review and act on population health dashboards to address care gaps (annual wellness visits, lack of symptom monitoring, missing labs, etc.)
  • Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience)
  • Knowledge of Chronic conditions especially targeting complex kidney and cardiac care conditions and associated co-morbidities
  • Minimum 2 years of experience in care coordination or ambulatory care for cardiac or kidney care
  • Prior experience interacting with patients primarily via telecommunication
  • Ability to work independently and efficiently in a remote environment
  • Excellent verbal communication: Capable of interacting with, and relating to, people of varying educational levels and backgrounds, conveying information clearly and succinctly, applying listening, tact, responsiveness, empathy, and confidentiality. Effective in communicating verbally with other staff and departments related to the job responsibilities.
  • Organization: Able to provide order and structure to daily processes and work environment. Demonstrates good organizational skills and ability to prioritize daily work.
  • Strong analytical and critical thinking skills. Strong community engagement and facilitation skills
  • Effective in identifying and analyzing problems. Proactively acts as a patient advocate and responds with resolve.
  • Core values consistent with a patient-centered approach to care. Ability to show empathy and quickly build relationships with patients and physicians
  • Teamwork: Must be able to get along with others, work as part of a team, accept constructive criticism, adapt behaviors quickly, and consistently follow and apply work rules. Works effectively with others to accomplish objectives and goals. Willingly offers assistance to others when the need arises. Fosters teamwork and positive rapport within all departments to maximize achievement of goals.
  • Computer Proficiency: Must be able to type 40 wpm on a keyboard-typing test required. Proficient in Microsoft Office and mobile phone and web-based application
  • Familiarity with Certified Case Manager program requirements
  • 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.
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