Specialty Care Coordinator

About the role

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.

Responsibilities

• 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.

Requirements

• Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience)
• Familiarity with Certified Case Manager program requirements, preferred
• 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

Qualifications

• Knowledge of Chronic conditions; kidney disease and congestive heart failure.

Skills