Transitional Care Associate Jobs in Elmhurst, IL

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.

The Supervisor, Care Management leads two integrated functions within Value-Based Care Primary Care: the Remote Care Management (TCM) team, which engages patients for 30 days following hospital discharge to coordinate care and reduce preventable readmissions, and the BCBS Delegated team, which is accountable for meeting annual population health management (PHM) goals under the BCBS delegation agreement. This is a dual-team, single-accountability role: the Supervisor owns performance, outcomes, and regulatory/contractual compliance across both functions and is directly accountable to leadership for results in each.

Cross-Team Leadership & Accountability

• Own combined performance for both the Remote TCM team and the BCBS Delegated team, holding direct accountability for readmission outcomes and annual PHM goal attainment.
• Report out regularly to VBC/Care Management leadership on performance against readmission and PHM targets, with corrective action plans when either team trends off-goal.
• Manage daily operations across both teams, providing proactive leadership that fosters optimal patient care, staff performance, and outcomes.
• Allocate staffing and workload across the two functions to ensure coverage and performance goals are met in both programs simultaneously.
• Promote a positive, collaborative work environment across both teams, reinforcing a shared culture of accountability.

Remote TCM Program (30-Day Post-Discharge / Readmission Reduction)

• Supervise remote Nurse Care Managers engaging patients for 30 days post-discharge to coordinate transitional care and prevent avoidable readmissions.
• Monitor readmission metrics at the individual and team level; identify root causes of preventable readmissions and drive corrective action.
• Meet regularly with direct reports to review cases and provide coaching on transitional care best practices.

BCBS Delegated Population Health Management

• Supervise the BCBS Delegated team to ensure the population meets or exceeds annual population health management goals as defined by the delegation agreement.
• Track PHM performance metrics (e.g., care gap closure, risk stratification outreach, quality/HEDIS-aligned measures) and drive team execution against annual targets.
• Ensure delegation compliance, partnering with contracting/quality teams to satisfy BCBS reporting, audit, and delegation oversight requirements.
• Analyze population health data from modeling and stratification tools to identify gaps in care and prioritize outreach.

Shared People & Program Management

• Own new employee onboarding for both teams, including interviewing/hiring, orientation planning, and ensuring training needs are met, with direct in-office supervision through the post-orientation phase.
• Develop and maintain educational resources to support staff needs across both the TCM and BCBS delegated functions.
• Conduct staff management activities, including performance evaluations, skill and career development, coaching on performance/behavior, and employee relations for both teams.
• Resolve escalated issues, supporting direct reports with timely resolution of patient/member complaints and inquiries across both programs.
• Perform additional duties as assigned.

• Remote TCM Team: 15 FTE RN Case Manager, 1 FTE MSW
• BCBS Delegated Team: [confirm current FTE count]

Total direct/indirect reports across both functions: [to be finalized upon posting]

License / Registration / Certification

• Current, unrestricted Illinois RN License, required
• Certification in Case Management, preferred

Level of Education

• Graduation from an accredited nursing program with an Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN); BSN preferred

Years of Experience

• 2+ years of Nursing experience in the primary care or hospital setting, required
• 2 years of Case Management experience, strongly preferred
• Experience with population health management and/or delegated health plan performance (e.g., HEDIS, risk stratification, care gap closure), strongly preferred
• Previous supervisor/manager experience leading multiple teams or programs simultaneously, preferred

• Accountability & Ownership: Holds self and both teams to clearly defined performance goals; escalates and resolves risk to readmission and PHM targets proactively.
• Analytical Thinking: Ability to analyze information across two distinct data sets (readmission and PHM performance), compare, contrast, trend data, and draw conclusions.
• Critical Thinking: Uses logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Leadership: Appropriately optimistic and inspiring; comfortable leading two teams with different workflows and goals; willing to take charge and drive execution.
• Resilience: Effectively manages competing priorities, stress, and ambiguity across dual accountabilities in a fast-paced setting.
• Communication: Communicates effectively to all levels and across functions of the organization; thinks clearly, communicates concisely, and collaborates consistently.

If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.
The compensation for this role includes a base pay range of 79K-118K, 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.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.