SNF, Social Worker

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. 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. Let’s start with what matters. People. Purpose. Care. At Duly Health and Care, we believe healthcare works best when it’s personal, connected, and led by people who truly care. We are a physician-led medical group built on trusted relationships, teamwork, and a shared commitment to putting patients first in every decision we make. Our team members are caregivers, collaborators, problem-solvers, and leaders. Together, we show up with compassion, act with purpose, and take ownership of the care we deliver and the experience we create. Whether you’re caring directly for patients or supporting the teams who do, your role matters here, and your voice is valued. We listen with intention, work as one, and challenge ourselves to keep improving, not for recognition, but because our patients, families, and communities count on us. Innovation at Duly isn’t about chasing what’s next for its own sake. It’s about finding better ways to deliver high-quality, affordable, and accessible care, today and into the future. If you’re looking for meaningful work, supportive teammates, and the opportunity to help shape the future of care while staying grounded in compassion and community, you’ll find your place at Duly. Current Duly Health and Care team members: Please do not apply through this external site. To be considered, log in to Workday through the OneDuly intranet and click on Career Opportunities to apply. This ensures your application is reviewed appropriately. If you have questions, please connect with your leader or HR Business Partner for support.