The incumbent will serve as a Physician in a Patient Aligned Care Team (PACT) setting. He/she will be responsible for providing medical care in an outpatient setting following PACT principles.

Duties include, but are not limited to:

• Utilizes all available tools, such as registries, to enable effective and efficient identification and intervention of individual patients and cohorts.
• Assures that clinical care provided meets all timelines and required documentation for the Chief of Staff (COS) office.
• Participates in multi-disciplinary team meetings to achieve a patient centered, holistic approach for clinical care and needs of the Veteran, focusing on continuous improvement of critical team processes. Ensures the patient's care plan contains medical recommendations for clinically indicated care.
• Ongoing, continuous care of one or more assigned panel(s) of Veterans providing health education and health coaching on wellness, disease prevention, chronic care management and self-management skills to patients and personal support persons.
• Collaborates with informatics technology staff to develop and implement systematized, electronically supported, standardized, tools to support PACT care delivery processes (e.g., pre-visit reminder calls, post hospitalization follow-up calls, recall scheduling procedures, new patient orientation, disease registries and primary care protocols for chronic disease management.