SNF, Social Worker

Duly Health and Care · United States

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.

• Location: Hybrid Opportunity with significant local travel: Cook, Kane & DuPage County
• Hours:Full-Time. 40 hours per week.
• Monday-Friday 8-5

• 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

• Lead discharge planning efforts in collaboration with SNF interdisciplinary teams
• Identify and address barriers to timely discharge (social, environmental, logistical)

• Home Health
• Outpatient follow-up
• Community resources
• Facilitate warm handoffs to Duly Care Management teams upon discharge

• 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

• 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

• Support appropriate utilization of SNF services
• Identify opportunities to reduce unnecessary length of stay
• Align discharge timing with clinical readiness and patient goals

• Maintain accurate and timely documentation
• Track and report patient outcomes and key metrics
• Perform additional duties as assigned

• 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

• EPIC or other EMR systems (preferred)
• Microsoft Office Suite (Excel, Word, PowerPoint)

• 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

INDHP