This is not the typical medical center. This Ambulatory Intensive Caring Unit takes care of the sickest & most vulnerable members of the Atlanta communitymembers who have been ill-served by the traditional healthcare system. When their members are spinning in the traditional health system, from ER to street and back this medical center finds a way to change the trajectory of the lives of their members by addressing root causes: whether its working with members to take the right medication, or having enough to eat, or addressing housing instability. They serve a very special population of very high needs members, who have been failed by the traditional health system. Job Summary: Reporting directly to the Medical Director, the internal/family medicine trained primary care provider utilizes their experience treating patients with multiple chronic diseases to deliver concierge-level care to our communitys most medically complex and socially vulnerable individuals. The Primary Care provider is responsible for helping develop transitional care plans for patients being discharged from hospitals, ERs, skilled nursing facilities, and any other venue that requires transitional care. This in turn lowers unnecessary ER utilization, inpatient utilization, specialty utilization, and readmissions while increasing the quality of care delivered. The PCP provides services including counseling patients regarding the most appropriate setting to meet their healthcare needs, performing assessments and evaluations of their problems, providing the appropriate information regarding specialist services, and end of life programs. Special attention is given to the PCMH model, evidence-based protocols and screening, and working as a collaborative team including physicians, case managers, social workers, psychologists, pharmacists, and nutritionists to educate and empower our patients to make healthier choices.Specific Duties and ResponsibilitiesComplex Clinical Care: Manage and improve health for patients with multiple complex and chronic medical conditions. Work with and lead a team (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team. Develop strong transitional care plans and able to track paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care. Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) in order to facilitate appropriate discharge to a lower level of care or back to the Medical Center. Familiar with inpatient medicine and the discharge process to facilitate discharges. Treat acute exacerbations of chronic conditions within the Medical Center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within Medical Center and when a higher level of care needed. Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified physician or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted. Track patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions. Understand the PCMH model of care as pertains to specialist care, only utilizing this higher level of care as needed, and not a substitute for a well-trained primary care physician with evidence based clinical skills. Educate members on chronic disease progression and the need for advanced directives where applicable. Practice evidenced based medicine in accordance with the PCMH model of care. Provider will work four, 10-hour days Education and Experience requirementsLicensed Physician in the state of GeorgiaBoard Certified in Internal Medicine or Family PracticeBLS certificationMission-Driven to serve the underservedStrong focus on customer serviceSuccess working as part of a multidisciplinary team with constant collaboration within and across provider teamsProficiency utilizing EMRProblem-solving and the ability to be creative in those solutionsStrong oral and written communication skillsPreferred qualificationsWork without ego, and thoughtfully build successful relationships with team members and our partnersExperience in population health managementExperience in working with psycho-socially and medically complex patients Our employees are offered the following benefitso Free parkingo Free Vision Plano Medical and Dental planso Life Insuranceo Short Term Disabilityo 401k Retirement planIf interested, please email CV to