Specialty Care Coordinator

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. 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. Specialty Care Coordinator 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. KNOWLEDGE SKILLS AND ABILITIES: 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 EDUCATION and / or CERTIFICATION/LICENSURE: Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience) Familiarity with Certified Case Manager program requirements, preferred EXPERIENCE: Knowledge of Chronic conditions; kidney disease and congestive heart failure. 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. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.