This is an incredible opportunity to impact patient outcomes. Population served are primarily seniors at risk and chronic illness.
This is a hybrid role - telemedicine and home visits
Locations covered - West Philadelphia and south Philly
- Patient volume per day - 5-6 home visits per day
- We provide company sponsored car
- Home visits - At least 4 days/week or depending on patient needs, etc. Possible 1 telehealth day per week
- 80% home visits, 20% telehealth
Position reports to the practice manager.
home care model offers:
+In-home primary care
+Health risk assessments
+Transition of care
+Post-acute acute care
+Home infusion therapy
Our client is the premier home based healthcare provider and medical services company that is a subsidiary for a $5B managed care organization
We are an innovative, multi-specialty practice experiencing tremendous growth nationwide.
Our focus is comprehensive care at home to improve outcomes and reduce total healthcare costs. We are a group of clinical professionals that understand the needs of patients, medical professionals, health systems and payers. A main focus of our practice is:
- Comprehensive Health Risk Assessments (HRA): health plans contract with the home Care to conduct in-home comprehensive health assessments in order to ensure patient’s medical well –being and to provide accurate data for HCC (Hierarchical Condition Categories) coding, STAR ratings and reimbursement.
- Complex Care Program (CCP): health plans look to us to conduct in-home longitudinal care for medically complex patients with chronic illnesses in an effort improve clinical outcomes. Our team collaborates with the patients’ primary care physicians (PCPs), and our visits serve as an adjunct to the care delivered by the PCP.
- Chronic Care Management (CCM): The Home Care contracts with and receives referrals from health plans to assume primary care of chronically ill patients with high admission rates and multiple emergency department visits in an effort to improve clinical outcomes. Nurse practitioners work alongside physicians delivering care in the patient’s home.
We are currently seeking additional Physicians to join our growing comprehensive Health Risk Assessment, Complex Care Program and Chronic Care Management teams as we further extend our operations serving a variety of Medicare Advantage, Medicaid, and Commercial clients.
- 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 patient’s 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, PCP’s (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 company's Care’s 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;
- Experience with electronic medical records is required. Also required is proficiency with various computer based applications such as Microsoft Office;
- Must have valid state driver’s license, be able to drive your car, provide your own vehicle, and have proof of adequate automobile insurance;
- Highly motivated, self-directed professional with strong organizational skills and comfortable working independently on a daily basis;
- Strong background/interest in primary care and preventative medicine;
- Excellent clinical assessment and analytical skills;
- Effective leadership and interpersonal skills; facilitates problem resolution and maintains a professional demeanor in difficult situations;
- Excellent verbal and written communication skills;
- Proven ability to perform comprehensive, adult and geriatric physical exams;
- Demonstrated ability to identify, diagnose and document acute and chronic disease in adults ;
- Demonstrated ability to recognize conditions, characteristics, and behaviors that place seniors at risk
- Proven ability to pursue feedback, continuing education and professional development;
- Candidate must be willing to travel up to a 30-60 miles radius from their home zip code;
- Proof of yearly influenza vaccination, Hepatitis B vaccination, and TB testing required. Covid Vaccine Status
- Board Certified (MD or DO) in Internal Medicine or Family Medicine
- Must have current BLS certification
- Must have active/unrestricted license in state of position opening
- Must be able to be credentialed by Medicare, Medicaid, and other Private Insurance Companies
Relocation Assistance Available - Possible for ideal candidate
5+ to 7 years’ experience
Schedule is Mon - Fri 8am - 5pm EST
Position requires on call every 6-8 weeks, and telehealth option where/when possible depending on patient needs.
Position will cover South and West Philadelphia