Lead Physician, Detroit, and Kalamazoo

Job Description

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 Field Team Physician will be based in our office in Kalamazoo but will include travel throughout the local area.



The Concerto Health Field Team is a robust, multi-disciplinary team that provides wrap-around services to patients in the home and community setting. Their aim is partner with provider groups to ensure effective and safe transitions of care, improve quality of care, and in doing so prevent unnecessary utilization (emergency department visits, inpatient admissions, readmissions).


The Field Team Physician must have a strong desire to build close relationships with all members of the Field Team and regional care management team, 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 Field Team Physician will work with members of a core field-based team (advanced practitioner, primary care nurse, clinical field team coordinator, patient engagement specialist) to address the social determinants of health, ensure safe transitions of care, maximize health outcomes, 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.



Responsibilities
-Delivery of home- and community-based primary care (preventive, acute, chronic care management) on a consulting or continuing basis to complex patients in an 8-county area in southwest Michigan

-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

-Ensure accurate and thorough clinical documentation and coding for all Field Team 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.

Qualifications
-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.

-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

-Public health and/or health administration studies, and/or advanced training in geriatric or palliative medicine preferred

-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.

-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.

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