Job Description
(Physician/MD qualifications required) Internal Medicine - Work from home and in the field - HYBRID role
We are an innovative, multi-specialty practice experiencing tremendous growth nationwide.
Duties & Responsibilities:
Function as day-to-day clinical leader, providing decision support to nurse practitioners and collaborating with the multidisciplinary team
Perform preventive visits daily to optimize chronic conditions, assess home environment, and develop proactive care plans
Educating patients and|or patients family on chronic medical conditions, preventative care, and medication adherence compliance;
Perform urgent care visits in the home and telephonically to avoid unnecessary ED transfers and hospital admissions
Leverage the support of care team such as: nurse care manager, behavioral health, social work, and pharmacy to meet patients medical, biopsychosocial, and financial needs
Assume responsibility as home based PCP in some cases where there is no PCP and in other cases co-manage the patient with the PCP and serve as an extension of clinical care into the home
Coordinate with other physicians across the continuum of care, including hospitalist, specialists, PCPs (in some cases), and SNF providers to smooth transitions and prevent readmissions
Perform Telehealth visits at times when needed
Complete appropriate and thorough clinical documentation of acute and chronic health issues through patient encounter in EMR system;
Complete EMR documentation in a timely manner; Ensuring all appropriate consent forms are signed and dated; Interpreting laboratory data and diagnostic testing when available to assist in diagnosis of medical conditions;
Performing ADL and fall risk assessments; cognitive impairment, depression, and nutritional health screening; BMI measurement; medication reconciliation;
Participating in frequent telephonic clinical meetings and web-based trainings; however, provider will occasionally be required to attend on-site training for which the provider will be reimbursed;
Complete chart reviews for advanced practice providers as determined by market Participating in quality processes such as medical documentation audits and quality projects;
Serving as a mentor or coach to advance practice providers in ongoing quality and performance improvement processes;
Improving provider relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships;
Performing other duties as assigned by the practice manager or medical director.
Perform HRA (health risk assessments) on patient panel
Interpreting laboratory data and diagnostic testing when available to assist in diagnosis of medical conditions;
Care Management duties:
Performing home visits with patients enrolled in Alegis Cares Complex Care Program. Initial visits are comprehensive evaluations with subsequent visits targeting risk factors for disease exacerbations and hospitalizations;
Collaborating with the multidisciplinary team which may include: patients PCPs and health plan case managers;
Sharing after hour on-call coverage with other providers on the team;
Working with telephonic|office nurse care coordinators and case managers;
Working with telephonic social workers (practice dependent);
Working with office medical assistants;
Having the ability and the experience to prescribe medications, order labs or diagnostic testing, and recommend sub-subspecialty referrals and collaborating with the community PCP if appropriate.
Knowledge, Skills, Abilities and Requirements:
Board Certification in Internal Medicine or Family Medicine;
Geriatric Medicine subspecialty training or experience preferred;
DEA license and State Controlled Substance license upon hire;
Strong background|interest in primary care and preventative medicine;
Job Tags
Work from home,