Primary Care Physician

Our client is seeking a dynamic, mission driven clinical leader to put the principles of team-based collaborative care and population health into action for our medically complex & socially vulnerable members. Our client is designed to care for society’s most complex patients under innovative value-based care arrangements. Their patients have typically been underserved by the traditional health care system, resulting in frequent bouncing between emergency rooms, hospitals, and specialists. Their health care teams break the status quo by transforming our members’ experience to improve quality of life and overall health outcomes while reducing high costs of unnecessary utilization. This exceptional care is provided by an integrated team of primary care providers, complex care managers, nurses, medical assistants, behavioral health clinicians, and community health workers. Our client offers complex, coordinated medical care with our onsite infusion center, full pharmacy, and lab & imaging suites. They also address the social determinants of health, addressing housing instability, food insecurity, and social isolation.

The Lead Physician, Primary Care provides direct clinical care to a panel of members. They guide clinicians on best practices on delivering value-based care. Additionally, they work closely with our Medical Director to provide clinical leadership to our providers, Nurses, Behavioral Health specialists, and Medical Assistants.

4 key areas for responsibility for the Lead Physician:

• Provide excellent primary care to a panel of members, leading your pod interdisciplinary care team
• Coach fellow providers in how to provide excellent primary care / urgent care / or community care to their members, and effectively lead their interdisciplinary care teams. Mentor care teams during population health huddle to achieve their quality and utilization goals.
• Alongside the Medical Director, the Lead Physician is the clinical leader in the center. They address questions from and provide clinical guidance to nurses, MAs, and fellow providers about clinical cases as they arise.
• The Lead Physician is core part of the center and market’s leadership team. They are accountable for driving the market toward successfully achieving its quality, utilization and engagement goals. Alongside the medical director, they partake in leadership meetings, and will also be our client's ambassador to community based organizations, hospital systems, and payer partners.

Duties and Responsibilities

• Provide Primary Care services to panel of members.
• Work in a team environment (with social work, care management, behavioral health, nursing, pharmacy, nutrition, etc.), process feedback, and facilitate discussion and implementing plans of care from other members of the team.
• Coach and mentor physicians and Advance Practice Providers.
• Treatment of acute exacerbations of chronic conditions onsite.
• 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.
• Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within client facility and when a higher level of care is needed.
• Work with Medical Director to forge partnerships with academic programs and community-based organizations to enhance provision of services to members.
• Vigilant in keeping track of patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
• Practice evidenced based medicine and in accordance with the PCMH model of care.
• Able to keep track of and successfully obtain specified quality metric goals.
• Perform other duties as required consistent with chronic care and disease management services provided to patients.
• Implement plans of care in collaboration with the patient, their family and other team members.
• Develop strong transitional care plans and able to keep track of paneled patients along the whole continuum of care including hospital discharges, ER, skilled nursing facilities and home care.
• Track and successfully obtain specified quality metric goals.
• Use technology and the electronic health record to the highest capability to increase quality initiatives and efficiency within the practice.
• Participate in multi-disciplinary meetings and recommend treatment initiatives designed to keep patients healthy or resolve ongoing clinical issues.
• Provide on-call coverage for the office in rotation with other providers.
• Develop clinical protocols and pathways to upskill all clinical support staff to practice top of license
• Approximately 70-80% time dedicated to direct clinical care.

Minimum Qualifications

• Active, unrestricted medical license in the state of employment.
• 2 years of clinical experience and administrative experience leading interdisciplinary teams.
• Experience working for a clinic, community-based organization & inpatient unit.
• Experience with training and mentoring.
• Excellent interpersonal communication skills.
• Strong problem solving, project management and organization skills.
• Independent self-starter and critical thinker interested in population health, healthcare utilization management, and the ongoing development of our care model.