Care@Home is designed to provide in-home patient care to our most complex patients living with multiple chronic conditions. The Field Based Rounding Physician will be the anchor to the assigned Care Team and will work in conjunction with the Primary Care Physician and Specialists to ensure and align with the Quadruple Aim: the patient receives the right care, at the right time, in the right setting and at the right cost.

The Care@Home Field Based Physician will provide high quality, evidence-based, in-home patient care to complex and high-risk patients.Primary goals and objectives: providing best-in-class patient care, reducing avoidable hospitalizations, decreasing unnecessary emergency department utilization, and increasing accurate risk adjustment factor scores.

Job Responsibilities/Duties

• Provides and manages direct patient care, including physical examinations, evaluations, assessments, diagnoses, counseling/education, and treatment for a specified population (panel) adhering to the highest standards of medical practice, ethics, professionalism and patient confidentiality at all times. Prescribes pharmaceuticals, other medications.
• Must be comfortable performing in-home procedures such as but not limited to: intravenous fluids and medications; nebulizer treatments; wound care; intramuscular injections; vaccinations, catheter insertion and removal.
• Discusses patients’ wishes for end-of-life care, as well as palliative and hospice care. Analyze records, reports, test results, or examination information and refers patients to specialists and to relevant patient care components as appropriate.
• In collaboration with the Primary Care Physician, APP staff and Care@Home Support team, promotes effective communication with patient, family/caregiver to encourage the role of the patient as a partner in health care and drive collaborative patient care decisions.
• Supports an environment of exchange and recommends improvements in all clinical areas. In general, drives areas to improve patient information exchange, overall patient satisfaction, experience and/or other operational areas to meet or exceed all Quality measures. Collects records and maintains patient information in EMR, such as medical history, reports and examination results. Performs accurate HCC coding at every visit, performs Annual Wellness Visits and closes all care gaps related to HEDIS, P4P, STARS or any other required programs. Must have excellent interpersonal skills and be able to deliver CAHPS scores above the 75th percentile.
• Must be comfortable working in a team environment. Functions as primary lead for POD team of clinicians in addition to managing attributed patient panel. Responsible for oversight of, and collaboration with APPs (NPs and PAs) and other supporting staff. Will function as lead to teach and mentor on clinical care. Responsible to conduct chart reviews and supervise NPs and PAs.

Qualifications

Minimum Education: MD or DO and possess an active, non- restricted California Medical License.

Minimum Experience: Minimal two to 3 (2-3) years of experiences in urgent care/outpatient clinic setting, experience in home-based care preferred. Significant experience with complex geriatric population is a must. Must be willing to provider in-home patient care and travel within assigned territory. Must be willing to be on-call, minimally 1 week per month. Dedicated to providing excellent healthcare and a top-quality patient experience. Consistently exhibit the highest levels of professionalism, integrity, accountability, and compassion. Excellent oral and written communications skills. Strong organizational and time management skills with the ability to manage patient panel. Must have high initiative, be flexible, and have the ability to handle and prioritize multiple tasks. Technically savvy and comfortable using tools such as EMR for charting and HIPAA secure messaging apps for care coordination. Experience with HCC coding, RAF and HEDIS measures preferred. EMR experience required. Palliative experience, preferred. Experience in providing care to patients with mild to moderate behavioral health conditions a plus.

Req. Certification/Licensure: CURES and DEA certification. Board certified or board eligible for Internal medicine, family practice or Emergency Medicine. ACLS certification required.