Job Description

This role provides physician services including counseling patients regarding the most appropriate setting to meet their healthcare needs, performing diagnostic evaluations and treatment, providing the appropriate information regarding specialist services, and end of life programs. This role functions as a part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.

Duties and Responsibilities

• Focus on the management and improvement of health for patients with multiple chronic medical conditions.
• 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.
• Treatment of some acute exacerbations of chronic conditions onsite.
• Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCARE and when a higher level of care is 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.
• Vigilant in keeping track of patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
• Assist with educating patients regarding their chronic diseases and healthy choices.
• 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 recommends treatment initiatives designed to keep patients healthy or resolve ongoing clinical issues.
• Provide on-call coverage for the office and hospital in rotation with other providers.

Minimum Qualifications

• Licensed physician in the state of practice.
• Board certified Internal Medicine or Family Practice.
• BLS certification required.
• Experience in population health management is preferred.
• Experience in working with psychosocially and medically complex patients is strongly preferred.
• Knowledge or experience with NCQA PCMH model is preferred.
• Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams.
• Innovative and creative and innovative self-starter to help solve patient's problems.
• Experience and comfort around maximizing EMR systems.
• Excellent interpersonal and communications skills.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Working knowledge of Microsoft Office Suite (Word, Outlook, PowerPoint, and Excel).

Working conditions

This job operates in a professional office environment. This role routinely uses general office equipment. -OR- This job operates in a professional office environment. This role routinely uses general office equipment. Often wear a special uniform, such as a lab coat or surgical scrubs, protective or safety attire, such as gloves and masks. Exposed to the diseases and infections of patients daily. May share workspace with other technicians and staff.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
• Job may be physically demanding at times.
• Repetitious Movements.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.