- Manage and improve health for patients with multiple complex and chronic medical conditions.
- Work with and lead a team (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team.
- Develop strong transitional care plans and able to track paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care.
- Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) in order to facilitate appropriate discharge to a lower level of care or back to the Medical Center. Familiar with inpatient medicine and the discharge process to facilitate discharges.
- Treat acute exacerbations of chronic conditions within the Medical Center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within Medical Center and when a higher level of care needed.
- Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified physician or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
- Track patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
- Understand the PCMH model of care as pertains to specialist care, only utilizing this higher level of care as needed, and not a substitute for a well-trained primary care physician with evidence based clinical skills.
- Educate members on chronic disease progression and the need for advanced directives where applicable.
- Practice evidenced based medicine in accordance with the PCMH model of care.
- Provider will work four, 10-hour days
- Licensed Physician in the state of Georgia
- Board Certified in Internal Medicine or Family Practice
- BLS certification
- Mission-Driven to serve the underserved
- Strong focus on customer service
- Success working as part of a multidisciplinary team with constant collaboration within and across provider teams
- Proficiency utilizing EMR
- Problem-solving and the ability to be creative in those solutions
- Strong oral and written communication skills
- Work without ego, and thoughtfully build successful relationships with team members and our partners
- Experience in population health management
- Experience in working with psycho-socially and medically complex patients
Our employees are offered the following benefits
o Free parking
o Free Vision Plan
o Medical and Dental plans
o Life Insurance
o Short Term Disability
o 401k Retirement plan
If interested, please email CV to [Register to View]