We are seeking a primary care physician to join an innovative team that is committed to improving care for underserved patients with complex-needs. Reporting to the Market Medical Director, the Lead Physician will be based in Kalamazoo Clinical Hub in Detroit and will include travel throughout an 8-county area in Southwestern Michigan.
The Field Team is a robust, multi-disciplinary team that provides wrap-around services to patients in their home to support our delivery of the right care, at the right place, at the right time, with the right care team member. Areas of focus include chronic disease management, safe and effective transitions of care, as well as preventing inappropriate utilization (emergency department visits, inpatient admissions, readmissions).
The Lead Physician must have a strong desire to build close relationships with all members of the field and regional care management teams, and be committed to working in a collaborative fashion to provide excellent care for patients. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Flexible and dynamic, a creative problem solver, this self-starting candidate will exhibit a high level of professionalism that allows them to lead and work effectively with a team of dynamic and unique individuals.
Our schedules allow providers to spend extended amounts of time with patients, allowing them to excel at relationship-based care, which is key to our care model. The Lead Physician will work with members of a core field-based team (advanced practitioner, primary care nurse, clinical and administrative field team coordinators, patient engagement specialist, behavioral health specialist) to address the social determinants of health, ensure safe transitions of care, maximize health outcomes through evidence-based disease management, and prevent avoidable healthcare utilization.
Concerto Field Team providers are expected to carry a panel of homebound or access-challenged members. A typical schedule could include up to 6 home visits in a day. The schedule is designed to provide a high level of attention and care to each patient. Approximately 20% of clinical time is provided for administrative duties.
This is an ideal position for a provider who has professional alignment to complex-need patients and underserved populations, enjoys a collaborative team-based work environment, and desires a challenging position that provides professional growth by allowing one to practice at the top of their license.
The Lead Physician performs all duties in a manner that reflects the mission, vision, and core values of the Concerto Health care model. He or she demonstrates dedication to and an aptitude for innovation, quality improvement, role optimization, and team-based care. This individual demonstrates versatility, flexibility, enthusiasm and the willingness and grit necessary to work with constantly changing priorities. Performs other duties as assigned.
- Graduation from an accredited medical school
- Board certified in Internal Medicine or Family Practice. Board Certification pending is acceptable with the understanding that the candidate must become Board Certified within one year.
- Additional board certification in geriatric or palliative care preferred
- Public health, business administration, and/or health administration studies preferred
- Active Medical License in the State of Michigan, or the ability to obtain one.
- Ideally three or more years’ experience since completion of residency, including home visit experience
- Must be experienced in diagnosing and treating the wide range of medical issues seen in the adult population including complex cases with multiple co-morbidities.
- Must be skilled in providing care for the whole person, including patients living with mental illness and substance use disorders, ideally certified to provide medication-assisted treatment
- Must be able and willing to coordinate care with internal members of the care team as well as external providers.
- Must be comfortable seeing patients in their homes and skilled nursing facilities
- Ideal candidates will want to work as advocates for their patients. They will also embrace the concept of team-work and mutual support of their colleagues, fostering a joyful work culture.
- Current CPR and BLS certification preferred
- Average to advanced computer & software skills (Microsoft Word, Excel, Outlook)
- Ability to work a flexible schedule, including periodic outreach duties evenings, nights, and weekends.
- Ability and means to travel as needed in a timely manner to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required. DRIVER REQUIREMENTS: Age 21; Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving with 7 years.
Essential Duties and Responsibilities
- Delivery of home- and community-based primary care (preventive, acute, chronic care management) on a consulting or continuing basis to complex patients
- Provide clinical supervision, coaching, and mentorship to an advanced practitioner, as well as to other members of the core care team
- Lead and collaborate with interdisciplinary team members – including advanced practitioners, pharmacists, pharmacy technicians, nurse care managers, patient services representatives, social workers and behavioral health professionals – to optimize care and outcomes
- Deliver timely healthcare services to patients after hospital discharge to facilitate continuing recovery and minimize readmissions
- Communicate closely with patients’ other healthcare providers so that primary and specialty care is well coordinated, including use of eConsult platform
- Ensure accurate and thorough clinical documentation and coding for all patients
- Conduct educational and quality improvement activities for Field Team members and other members of the interdisciplinary care team
- Build a successful home visit practice that carries an excellent reputation among area patients and healthcare professionals
- Performing other duties as assigned.