Duly Health and Care·Wheaton, Illinois
The Patient Care Navigator supports high-risk patients through pre-visit planning, clinical monitoring, and care coordination within value-based care programs. They are responsible for tracking quality metrics, performing clinical procedures, and managing patient documentation in the EHR.
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.
Under the direction of the Site Physician(s), Care Ally RN, and Supervisor/Director of Care Management, the Patient Care Navigator serves as a key member of the interdisciplinary care team supporting high-risk and rising-risk patients within value-based care programs.
The Patient Care Navigator functions at the top of their scope to support population health initiatives, quality measure performance, risk adjustment accuracy, and care coordination activities aligned with organizational value-based contracts (including programs supported by the Centers for Medicare & Medicaid Services and Medicare Advantage plans). The role combines direct patient care, proactive panel management, preventive care outreach, transitional care support, and structured documentation to improve clinical outcomes and reduce avoidable utilization.
Performs protocol-driven clinical monitoring to support chronic disease management and value-based quality outcomes. Obtains and documents vital signs including blood pressure, heart rate, respiratory rate, temperature, weight, BMI, and pulse oximetry. Performs point-of-care testing such as blood glucose monitoring and other ordered tests within scope.
Conducts repeat blood pressure checks for patients with elevated readings. Collects and documents home monitoring data, including patient-reported blood pressure readings, glucose logs, weight logs (for heart failure monitoring), and pulse oximetry readings when applicable.
Identifies abnormal findings and escalates to the Provider or Care Ally Nurse in accordance with established clinical protocols.
Utilizes appropriate EHR functions (including Hyperspace/Epic workflows, where applicable) to facilitate patient flow, panel management, and quality metric capture.
Documents patient information including medications, reasons for visit, vitals, screenings, and structured quality data elements.
Ensures lab, imaging, and diagnostic results are correctly documented and routed.
Pulls discharge reports from hospital portals and obtains medical records from hospitals not utilizing Epic or shared EHR platforms.
Completes documentation support for Transitional Care Management (TCM), Chronic Care Management (CCM), High-Intensity Care visits, and Annual Wellness Visits as directed.
Administers and documents Social Determinants of Health (SDOH) screenings as applicable.
Manages incoming faxes, in-basket requests, and electronic communications in a timely and organized manner.
Assists nurse and providers with medication refill workflows after appropriate review and approval.
Coordinates communication with pharmacies and specialists as directed.
Routes urgent or clinically significant communications to Provider or Case Management Nurse per protocol.
Accredited Medical or Nursing Assistant Program or
EMT-B
Equivalent experience.
Preferred one-year experience in a medical setting such as a doctor’s office, hospital or long-term nursing facility.
Must be experienced in PC/keyboard skills and Microsoft office applications.
Must possess excellent communication and writing skills.
Must have the ability to plan, organize, and work independently; exhibits problem-solving skills.
Able to develop professional rapport with employees at all levels of the company.
Must be able to perform CPR when necessary.
Practices OSHA safety standards and complies with HIPAA at all times.
The compensation for this role includes a base pay range of $21.43-23.63 for a Medical Assistant; Certified or Registered Medical Assistant the base pay range is $22.97-24.57, 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.
Requires a high school diploma or GED and completion of an accredited Medical/Nursing Assistant program or EMT-B. Preferred candidates have one year of experience in a medical setting and proficiency in Microsoft Office.
Market context
In Illinois, support-services roles like this are typically competitive because employers look for a mix of early-career experience, an associate’s degree or equivalent training, and active imaging credentials. For this position, licensure and certification details matter, including ARRT status, an IEMA license, and CT certification within 13 months of hire. This platform AI-summarizes requirements and benefits from the original job description, saving you research time; before applying, verify your credentials and timeline against the posting.