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 sInstitutional Special Needs Plan (ISNP) program. This role partners closely with aninterdisciplinary care team to deliver high-quality, value-based care with a focus onimproving clinical outcomes, reducing avoidable hospitalizations, and supportingpatients in long-term care (LTC), skilled nursing facilities (SNF), and otherinstitutional settings.The physician provides longitudinal care management, completes timely assessments,coordinates transitions of care, and supports CareMore s mission of improving thehealth and well-being of vulnerable populations through proactive and evidence-basedcare. Key Responsibilities: Clinical Care & Patient Management:Deliver high-quality primary care services to ISNP members with complexchronic 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 diseasemanagement and preventive care interventions.Provide timely diagnosis and treatment while aligning with evidence-basedguidelines and CareMore clinical protocols.Care Coordination & Transitions of CareCoordinate care with nurses, care managers, social workers, specialists, facilitystaff, 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 careplanning, and health education.Documentation & ComplianceEnsure accurate, thorough, and timely documentation in the electronic medicalrecord (EMR).Complete required documentation supporting quality, risk adjustment, andprogram compliance.Follow all regulatory requirements and internal policies related to CMS, ISNPstandards, and institutional care.Quality, Outcomes & Value-Based CareSupport achievement of clinical and quality outcomes including preventivescreenings, chronic disease measures, and patient experience.Participate in initiatives aimed at reducing avoidable emergency departmentvisits, readmissions, and total cost of care.Contribute to continuous improvement efforts through participation in clinicalreviews, team huddles, and process improvement work.Professional Practice & Team CollaborationDemonstrate clinical leadership and act as a trusted partner to the care team andfacility partners.Participate in interdisciplinary case conferences, care planning meetings, andclinical operations discussions as needed.Maintain a culture of compassion, respect, accountability, and excellence inpatient care. Minimum Qualifications: MD or DO from an accredited medical school.Completion of an accredited residency program in Family Medicine, InternalMedicine, 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 medicallycomplex populations.Experience providing care in institutional settings such as Skilled NursingFacilities (SNF), Long-Term Care (LTC), Assisted Living or post-acuteenvironmentsKnowledge of value-based care models, Medicare Advantage, HEDIS, Stars, andrisk adjustment/HCC documentation.Comfort working collaboratively in a multidisciplinary care model.Strong communication and relationship-building skills with patients, families, andfacility 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 requiredpatient assessments.Ability to work with standard office and clinical equipment. Core Competencies Patient-centered care with a commitment to service excellenceClinical quality and evidence-based decision makingStrong collaboration and interdisciplinary teamworkAccountability and integrityEfficient documentation and attention to detailAdaptability in a fast-paced healthcare environment