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Position Summary :
Opportunity : Provide appropriate, patient-centered care to high-risk, medically vulnerable patients, often suffering from multiple chronic conditions, when and where they need it.
This patient-centric, continuous care model delivers clinical, economic, and human benefits.
Mission : Patient Care Medical Group seeks to understand a patient’s physical, emotional, and social conditions to provide patient specific care with the goal of achieving an optimal level of success.
Solution : Facilitation of timely interventions when chronic conditions worsen and preempting avoidable emergency department visits and hospitalizations, alleviating social stressors that contribute to poor health, and comforting patients by giving them loving care and letting them know they are not alone.
Care Settings : Post-Acute Care (PAC), Skilled Nursing facilities, Community / Home Care Patients, Assisted Living, Telehealth
Essential Functions :
- Examines patients, record medical history, address patient concerns, answer patient questions.
- Provides a continuum, or gap coverage in medical care for patients within a variety of health care settings.
- Participates in facility rounds.
- Diagnosis and manage chronic illness, disease, injuries, and / or long-term conditions.
- Set appointments and review clients for telemedicine visits; document visit in EHR.
- Review any abnormal vitals and labs and make appropriate recommendations.
- Make referrals to necessary and appropriate parties, including specialists and other skilled and non-skilled parties as indicated by patient need.
- Review assigned new admissions and their orders; complete plan of care.
- Serves as a liaison between patient and established primary care physician (if applicable); communicates with patients’ PCP regularly regarding any patient health updates, concerns or changes in care.
- Review discharge instructions including medication updates.
- Coordinate additional services within health care settings such as physical therapy.
- Participate in readmission review meetings and provide a summary of all PCMG acute discharges using the acute discharge worksheet and will review PCMG patients weekly with IDT (interdisciplinary team).
- Functions independently to perform age-appropriate history and physical for complex acute, critical, and chronically ill patients.
- Orders and interprets diagnostic and therapeutic tests relative to patient’s age-specific needs and explains results to the patient.
- Prescribes appropriate pharmacologic and non-pharmacologic treatment modalities.
- Implements interventions to support the patient to regain or maintain physiologic stability, including but not limited to serving as the first point of contact for admissions.
- Monitors the effectiveness of interventions and makes adjustment in care plan as needed.
- Facilitates the patient’s transition within and between health care settings, e.g. admitting, transferring, and discharging patients.
- Collaborates with multidisciplinary team members by making appropriate referrals.
- Facilitates staff, patient and family decision making by providing educational tools.
- Complies with all state medical laws and regulations (i.e. HIPAA).
Experience and Education :
- Medical Degree from a College or University and two years related experience and / or training.
- State license and certification to practice medicine.
Physical Requirements :
Standing (1 / 3-2 / 3), walking (over 1 / 3-2 / 3), using hands to finger, handle or feel (over 2 / 3), reach with hands and arms (over 1 / 3), climb and balance (under 1 / 3), stoop, kneel (1 / 2-2 / 3), talk or hear (1 / 2-2 / 3), smell (under 1 / 3).
Lifting up to 10 pounds (over 2 / 3), Up to 25 pounds (1 / 3-2 / 3); Up to 50 pounds (under 1 / 3)
We are an equal opportunity employer and we are committed to a work environment that promotes diversity, equity, and inclusion
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