Patient Care Navigator CMA​/MA- Wheaton

Overview

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.

• 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.

• Full Time
• Location:
  
  Wheaton
• Clinic
  
  Hours:
  
  Monday through Friday 8am-5pm

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.

• Identification of care gaps and screenings needed per quality metrics (e.g., mammogram, DEXA scan, colorectal screening, immunizations)
• Review of open lab and imaging orders
• Preparation for Annual Wellness Visits (AWV) and High‑Intensity Care (HIC) visits
• Review of recent hospitalizations or emergency department visits

• Monthly HIC visits
• Specialist appointments
• Preventive screenings aligned with quality metrics
• Lab and imaging appointments

• 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.

• Tracking and following up on incomplete orders (labs, imaging, diagnostic testing)
• Ensuring completion and documentation of preventive screenings
• Assisting with quality audits and chart reviews as directed

• 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…