Internal Medicine Physician

$20,000 sign-on bonus
The Primary Care Physician (PCP), ISNP is responsible for providing comprehensive,
patient-centered primary care to a complex senior population enrolled in CareMore s
Institutional Special Needs Plan (ISNP) program. This role partners closely with an
interdisciplinary care team to deliver high-quality, value-based care with a focus on
improving clinical outcomes, reducing avoidable hospitalizations, and supporting
patients in long-term care (LTC), skilled nursing facilities (SNF), and other
institutional settings .

The physician provides longitudinal care management, completes timely assessments,
coordinates transitions of care, and supports CareMore s mission of improving the
health and well-being of vulnerable populations through proactive and evidence-based
care.

Clinical Care & Patient Management:

• Deliver high-quality primary care services to ISNP members with complex

• chronic conditions in institutional settings (e.g., SNF/LTC).

• Conduct comprehensive patient assessments, including admission evaluations,

• routine follow-ups, and acute visits as clinically indicated.

• Develop and manage individualized care plans, including chronic disease

• management and preventive care interventions.

• Provide timely diagnosis and treatment while aligning with evidence-based

• guidelines and CareMore clinical protocols.

Care Coordination & Transitions of Care

• Coordinate care with nurses, care managers, social workers, specialists, facility

• staff, and other interdisciplinary team members.

• Manage transitions of care including post-acute follow-ups, hospital discharges,

• readmission prevention, and medication reconciliation.

• Collaborate with patients and families to support care goals, advanced care

• planning, and health education.

Documentation & Compliance

• Ensure accurate, thorough, and timely documentation in the electronic medical

• record (EMR).

• Complete required documentation supporting quality, risk adjustment, and

• program compliance.

• Follow all regulatory requirements and internal policies related to CMS, ISNP

• standards, and institutional care.

Quality, Outcomes & Value-Based Care

• Support achievement of clinical and quality outcomes including preventive

• screenings, chronic disease measures, and patient experience.

• Participate in initiatives aimed at reducing avoidable emergency department

• visits, readmissions, and total cost of care.

• Contribute to continuous improvement efforts through participation in clinical

• reviews, team huddles, and process improvement work.

Professional Practice & Team Collaboration

• Demonstrate clinical leadership and act as a trusted partner to the care team and

• facility partners.

• Participate in interdisciplinary case conferences, care planning meetings, and

• clinical operations discussions as needed.

• Maintain a culture of compassion, respect, accountability, and excellence in

• patient care.

• MD or DO from an accredited medical school.

• Completion of an accredited residency program in Family Medicine, Internal

• Medicine, or Geriatrics (preferred)

• Current, unrestricted medical license in the state of practice (or ability to obtain).

• Board Certified or Board Eligible in Family Medicine or Internal Medicine.

• DEA license

• 2+ years of experience providing primary care to seniors and/or medically

• complex populations.

• Experience providing care in institutional settings such as Skilled Nursing

• Facilities (SNF), Long-Term Care (LTC), Assisted Living or post-acute

• environments

• Knowledge of value-based care models, Medicare Advantage, HEDIS, Stars, and

• risk adjustment/HCC documentation.

• Comfort working collaboratively in a multidisciplinary care model.

• Strong communication and relationship-building skills with patients, families, and

• facility partners.

• Primarily facility-based and/or field-based in institutional settings.

• May require travel between assigned facilities and/or CareMore locations.

• Ability to sit, stand, and walk throughout the workday and perform required

• patient assessments.

• Ability to work with standard office and clinical equipment.

• Patient-centered care with a commitment to service excellence

• Clinical quality and evidence-based decision making

• Strong collaboration and interdisciplinary teamwork

• Accountability and integrity

• Efficient documentation and attention to detail

• Adaptability in a fast-paced healthcare environment