Come Join our Kalamazoo, MI Field-Based Care Team!

JOB SUMMARY

We are seeking a primary care physician leader to join our innovative team in Michigan who is committed to improving care for underserved patients with complex-needs. Reporting to the Chief Care Transformation Office, the Lead Physician, Field Team, will be based in our office in Kalamazoo but will include travel throughout the local area. The Lead Physician, Field Team, must have a strong desire to build close relationships with all members of the Field Team and care management team, and be committed to working in a collaborative fashion to provide excellent care for patients. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Flexible and dynamic, a creative problem solver, this self-starting candidate will exhibit a high level of professionalism that allows them to lead and work effectively with a team of dynamic and unique individuals. Our schedules allow providers to spend extended amounts of time with patients, allowing them to excel at relationship-based care, which is key to our care model. The lead physician will also work with members of a multi-disciplinary team (nurse practitioner, physician assistant, nurse care manager, clinical social worker, clinical pharmacist, and behavioral health specialist) to address the social determinants of health, smooth transitions of care, maximize health outcomes, and prevent avoidable healthcare utilization. Concerto Field Team providers are expected to carry a panel of homebound or access-challenged members. A typical schedule could include up to 6 home visits in a day. One to two half-days a week are set aside for administrative and educational activities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• - Administer primary care on a consulting or continuing basis at home visits to complex patients in an 8-county area in southwest Michigan

• - Provide clinical supervision for a nurse practitioner and/or physician assistant who makes home visits to complex patients

• - Lead and collaborate with interdisciplinary team members – including nurse practitioners and/or physician assistants, pharmacists, pharmacy technicians, nurse care managers, patient services representatives, social workers and behavioral health professionals – to optimize care and outcomes

• - Deliver timely healthcare services to patients after hospital discharge to facilitate continuing recovery and minimize readmissions

• - Communicate closely with patients’ other healthcare providers so that primary and specialty care is well coordinated

• - Ensure accurate and thorough documentation and coding for all Field Team patients

• - Conduct educational and quality improvement activities for Field Team members and other members of the interdisciplinary care team

• - Build a successful home visit practice that carries an excellent reputation among area patients and healthcare professionals

QUALIFICATIONS

• Graduation from an accredited medical school

• Board Certified in Internal Medicine or Family Practice. Board Certification pending is acceptable with the understanding that the candidate must become Board Certified within one year.

• Active Medical License in the State of Michigan, or the ability to obtain one.

• Ideally three or more years’ experience since completion of residency

• Public health and/or health administration studies, and/or advanced training in geriatric or palliative medicine preferred

• Must be experienced in diagnosing and treating the wide range of medical issues seen in the adult population including complex cases with multiple co-morbidities.

• Must be skilled in providing care for the whole person, including patients living with mental illness and substance use disorders.

• Must be able and willing to coordinate care with internal members of the care team as well as external providers.

• Must be comfortable seeing patients in their homes and skilled nursing facilities

• Ideal candidates will want to work as advocates for their patients. They will also embrace the concept of team-work and mutual support of their colleagues.

• Average to advanced computer & software skills (Microsoft Word, Excel, Outlook)