Specialty Care Coordinator

Duly Health and Care • Downers Grove, IL

7h • Hybrid

About The Position

The Specialty Care Coordinator is a critical member of an integrated specialty care team consisting of nurses, dietitians, pharmacists, care coordinators, and physicians. This role involves collaborating 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. The position does not require RN licensure but demands strong clinical acumen, attention to detail, and the ability to navigate complex care environments. The primary focus is 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. Coordinators will utilize predictive data to identify high-risk patients and integrate high-touch care workflows with Duly’s primary and specialty care providers. While primarily conducted via telecommunication, the role may require periodic in-person collaboration. This individual serves as a single point-of-contact to coordinate resources, identify gaps, and provide proactive follow-up, ensuring connected care and communication across various patient locations.

Requirements

• Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience)
• Familiarity with Certified Case Manager program
• Knowledge of Chronic conditions; kidney disease and congestive heart failure.
• 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

Nice To Haves

• Minimum 2 years of experience in care coordination or ambulatory care for cardiac or kidney care, preferred.
• Prior experience interacting with patients primarily via telecommunication, preferred.

Responsibilities

• Conducts scheduled telephonic outreach to high-risk and complex patients to understand their needs, track how they are following their care plan, 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 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.
• Serve as point person for non-clinical inbound calls from patient panel and escalate clinical requests to RN Care Managers.
• Assess home safety and social determinants of health (SDOH) barriers, including transportation needs.
• Provide general patient and caregiver education and promote evidence-based self-management strategies, from existing documentation.
• Review and document patient updates and progress.
• Utilize data collected from the predictive modeling tools to identify eligible patients for care management.

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: Entry Level
• Education Level: No Education Listed