Internal Medicine - Physician

Job Description

Job DescriptionInternal Medicine - Physician Position Overview

As an Internal Medicine Physician, you will deliver comprehensive healthcare services to patients with complex medical needs and chronic illnesses. Your primary focus will be on managing their health conditions to minimize hospital visits and enhance their overall quality of life. You will lead multidisciplinary teams, coordinate transitional care, and address acute exacerbations within a patient-centered medical home framework. This role prioritizes evidence-based practices, community involvement, and overcoming healthcare barriers for at-risk populations.

Why Join Our Organization?

We are dedicated to serving some of the most vulnerable individuals in our communities—those at higher risk for diseases or managing multiple chronic conditions. Many of these patients face challenges within the healthcare system, often resorting to emergency rooms for basic care. Our mission is to transform these individuals into members who receive some of the highest quality, focused care available.

We refer to our approach as “care beyond medicine.” Our facilities function as comprehensive care centers, where we provide a core team of healthcare professionals—including doctors, nurses, social workers, and medical assistants—who are committed to understanding and addressing our members’ needs. Essential services such as pharmacy, X-rays, blood labs, nutrition counseling, and urgent care are all conveniently located under one roof.

Our commitment extends beyond our facilities. We actively engage with the communities we serve to identify those who need our assistance the most. Through our community care teams, we work to eliminate the obstacles that many individuals face in accessing healthcare. And our approach is proving effective.

Our distinctive care model is anchored in our core values of accountability, compassion, trust, and teamwork, which we collectively refer to as ACT2.

Key Responsibilities:

Complex Clinical Care:

• Manage and enhance the health of patients with multiple chronic medical conditions.
• Collaborate with a multidisciplinary team (including social work, case management, behavioral health, pharmacy, and nutrition) to process feedback and implement care plans.
• Develop effective transitional care plans and monitor patients throughout their care continuum, including discharges from hospitals, emergency rooms, skilled nursing facilities, and home care.
• Communicate with various care facilities to facilitate appropriate discharges to lower levels of care or back to our medical center, ensuring familiarity with inpatient medicine and discharge processes.
• Address acute exacerbations of chronic conditions within our center, such as administering Lasix for CHF or IV antibiotics for infections, while determining when higher-level care is necessary.
• Accept urgent appointments for patients needing immediate physician or case management services to prevent hospital admissions or readmissions.
• Monitor patients and their health conditions vigilantly to reduce emergency room visits and hospital admissions.
• Understand the Patient-Centered Medical Home (PCMH) model and utilize specialist care only when necessary, ensuring it complements primary care.
• Educate members about chronic disease progression and the importance of advanced directives when applicable.
• Practice evidence-based medicine in alignment with the PCMH model.

Qualifications:

• Licensed Physician in the relevant state.
• Board certified in Internal Medicine or Family Practice.
• Current BLS certification.
• DEA registration.
• Passionate about serving underserved populations.
• Ability to foster successful relationships with team members and partners without ego.
• Experience working collaboratively within a multidisciplinary team.
• Proficient in using Electronic Medical Records (EMR).
• Strong problem-solving skills and creativity in developing solutions.

Preferred Qualifications:

• Experience in population health management.
• Background in working with patients who have complex psycho-social and medical needs.

Keywords:

Internal Medicine, Chronic Disease Management, Patient Care, Transitional Care, Multidisciplinary Team, Population Health, Primary Care, Evidence-Based Medicine, Healthcare for Vulnerable Populations, Emergency Room Avoidance