Geriatrician

Job Description

Job Description

The Geriatrician is responsible for delivering comprehensive, patient-focused medical services to elderly individuals in two main environments: (1) outpatient clinics and (2) community settings. This position is designed to allocate 50% of the time to in-clinic activities (such as evaluations, ongoing management, and consultations) and 50% to community engagements (including home-based primary care, visits to assisted living facilities and skilled nursing facilities, transitional care, and outreach efforts). The clinician will prioritize functionality, quality of life, medication safety, alignment of care goals, and seamless coordination throughout the care continuum.

• Schedule: Full-time, with a 50% clinic / 50% community split

• Clinic Location(s): Attleboro, MA

• Community Coverage Area: Bristol & Norfolk Counties

• Travel: Required for community visits; must possess a valid driver’s license and reliable transportation

• On-call: None / Shared rotation / After-hours phone triage

Comprehensive Geriatric Assessment

• Conduct thorough evaluations that encompass medical complexity, functional abilities, cognitive health, mood, fall risk, nutritional status, sensory impairments, caregiver support, and social determinants of health.

Chronic Disease Management

• Implement evidence-based management strategies for prevalent geriatric conditions such as frailty, dementia, delirium risk, polypharmacy, osteoporosis, urinary incontinence, heart failure, COPD, and diabetes in older adults.

Medication Optimization

• Conduct structured medication reviews, deprescribing when necessary, and ensure reconciliation following transitions of care.

Cognitive and Behavioral Health Care

• Diagnose and manage conditions such as dementia, mild cognitive impairment, delirium risk, depression, anxiety, and behavioral symptoms in collaboration with caregivers and community resources.

Preventive Care & Risk Reduction

• Customize screening and preventive measures based on life expectancy, functional status, patient values, and clinical context; focus on fall prevention and mobility maintenance.

Care Planning & Advance Care Planning

• Facilitate discussions regarding care goals; document advanced directives/POLST/MOLST as needed; ensure treatment plans reflect patient preferences.

Consultation & Co-Management

• Provide geriatric consultations for complex cases and collaborate with primary care providers and specialists.

Home-Based and Community Geriatrics

• Deliver medical services in patients' homes and community settings (e.g., assisted living, adult day programs, supportive housing) for those facing mobility, cognitive, or access challenges.

Post-Acute & Facility-Based Rounding (as applicable)

• Conduct continuity visits in skilled nursing facilities (SNFs) or other residential environments, coordinating with facility staff on care plans and safety measures.

Transitional Care Management

• Assist with transitions from hospital to home (or SNF to home), ensuring timely follow-up, medication reconciliation, symptom monitoring, and coordination with home health services and caregivers.

Urgent Access & Acute Issue Management (in scope)

• Assess and manage subacute changes (e.g., triggers for delirium, falls, dehydration, infection risks) while minimizing unnecessary emergency department visits or hospitalizations when clinically appropriate.

Interdisciplinary Team Collaboration

• Work alongside nursing, social work, care management, pharmacy, physical therapy/occupational therapy, behavioral health, and community organizations to address both medical and social needs.

Caregiver Support & Education

• Offer coaching to caregivers, provide anticipatory guidance, and connect them with community resources.

Safety & Environmental Assessment

• Identify potential home safety risks (such as fall hazards, medication storage issues, nutrition access, and caregiver strain) and implement strategies to mitigate these risks.

• Documentation & Coding

  • Ensure timely and accurate documentation in the electronic health record (EHR); verify appropriate billing and coding for both clinic and community services.

• Quality & Population Health

  • Engage in quality improvement initiatives (e.g., falls prevention, polypharmacy management, reducing avoidable utilization, readmissions, and dementia care metrics).

• Communication

  • Maintain clear communication with patients, families, caregivers, and referring clinicians; provide concise summaries of care and follow-up plans.

• Compliance & Safety

  • Follow organizational policies, privacy regulations, infection control standards, and safety protocols for community visits.

• Teaching/Leadership (optional)

  • Mentor learners (residents, fellows, students) and contribute to the development of geriatrics and community care programs.

• MD or DO from an accredited institution

• Board Certified/Board Eligible in Geriatric Medicine (or Internal Medicine/Family Medicine with geriatrics expertise), as per organizational standards

• Unrestricted medical license (or eligibility) in MA

• DEA registration (or eligibility)

• Proven experience with complex older adults, chronic disease management, and interdisciplinary care

• Willingness to travel for community visits; valid driver’s license required

• Experience in home-based primary care , PACE, SNF/ALF rounding, or complex care management programs

• Training or experience in palliative care , dementia care, or transitional care

• Familiarity with telehealth and remote monitoring technologies

• Previous involvement in quality improvement or program development

• Expertise in geriatrics: frailty, multimorbidity, functional decline, cognitive disorders, polypharmacy, falls

• Strong clinical judgment in making risk/benefit decisions for older adults

• Patient- and family-centered communication; emphasis on shared decision-making

• Team-based care, care coordination, and systems thinking

• Cultural humility and a commitment to health equity

• Organizational skills for mobile/community practice (time management, routing, documentation)

• Ability to work in outpatient clinical settings and community environments (homes/facilities)

• May require standing or walking, transporting medical equipment, and navigating various home environments (stairs, pets, limited space)

Salary Range: $196,992.72 - $313,150.49

Our organization is an equal opportunity employer. We do not discriminate based on race, color, creed, age, gender, sexual orientation, national origin, veteran status, or disability.