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:
Position Highlights:
Location: Hybrid Opportunity with significant local travel: Cook, Kane & DuPage County
Hours:Full-Time. 40 hours per week.
Monday-Friday 8-5
The Post-Acute Network Care Coordinator (Licensed Social Worker) plays a critical role in managing day-to-day skilled nursing facility (SNF) patient populations. This role is responsible for coordinating care, facilitating discharge planning, and addressing psychosocial and environmental barriers to ensure patients receive the most appropriate level of care. Working closely with SNF staff, physicians, and interdisciplinary teams, the Care Coordinator drives efficient length of stay, supports safe transitions, and helps prevent avoidable hospital readmissions. This role partners with an RN Case Manager, who provides clinical oversight and support for high-risk or complex medical needs requiring escalation.
SNF Census Management & Care Coordination
Manage a daily/weekly census of patients across assigned SNF facilities
Serve as the primary point of contact for day-to-day coordination within SNFs
Maintain an active patient tracking system and provide regular status updates
Discharge Planning & Transitions of Care
Lead discharge planning efforts in collaboration with SNF interdisciplinary teams
Identify and address barriers to timely discharge (social, environmental, logistical)
Coordinate post-discharge services including:
Home Health
Outpatient follow-up
Community resources
Facilitate warm handoffs to Duly Care Management teams upon discharge
Patient Advocacy & Barrier Resolution
Assess patients' psychosocial, environmental, and support needs
Advocate for appropriate level of care based on patient goals and clinical status
Escalate complex medical or high-risk cases to RN Case Manager for clinical review
Care Coordination & Communication
Collaborate with SNF staff, physicians, and care teams to align on care plans
Participate in facility rounds and case discussions
Communicate updates, risks, and opportunities in real time
Utilization & Length of Stay Management
Support appropriate utilization of SNF services
Identify opportunities to reduce unnecessary length of stay
Align discharge timing with clinical readiness and patient goals
Administrative Responsibilities
Maintain accurate and timely documentation
Track and report patient outcomes and key metrics
Perform additional duties as assigned
Qualifications:
If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.
Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) - State of Illinois- Required
Strong understanding of SNF workflows, discharge planning, and care transitions
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
SNF, hospital, or post-acute settings
Experience with discharge planning and transitions of care strongly preferred
Experience working in value-based care or managed populations preferred
The compensation for this role includes a base pay range of $58,000-75,000, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.