Internal Medicine Physician

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. Key Responsibilities: 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. Minimum Qualifications: * 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 Preferred Qualifications * 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. Work Environment & Physical Requirements * 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. Core Competencies * 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 by Jobble