Specific Duties and Responsibilities
Complex Clinical Care :
- Focuses on the management and improvement of health for patients with multiple complex and chronic medical conditions.
- Able to work with and lead a team (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team.
- Develop strong transitional care plans and able to help keep track of paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities / nursing homes, and home care.
- Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) to facilitate appropriate discharge to a lower level of care or back to the AbsoluteCare Medical Center.
Familiar with inpatient medicine and the discharge process to help facilitate discharges.
Treat acute exacerbations of chronic conditions within the AbsoluteCare center, i.e. Lasix for CHF, IVF for Dehydration / Renal Failure, IV antibiotics for various infections, Nebulizer / Solumedrol for COPD / Asthma etc.
Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care 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.
- Understand the PCMH model of care as pertains to specialist care, only utilizing this higher level of care as needed, and not a substitute for a well-trained primary care physician with evidence based clinical skills.
- Educate members on chronic disease progression and the need for advanced directives where applicable.
- Practices evidenced based medicine and in accordance with the PCMH model of care.
Candidate Qualifications
- Full Unrestricted Maryland Medical License
- Board certified in Internal Medicine or Family Practice
- BLS certification required
- Mission-Driven to serve the underserved
- Work without ego, and thoughtfully build successful relationships with team members and our partners
- Ability to work as part of a multidisciplinary team with constant collaboration within and across provider teams
- Experience and comfort utilizing EMR
- Problem-solving and the ability to be creative in those solutions
Preferred qualifications :
- Experience in population health management
- Experience in working with psycho-socially and medically complex patient population
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