Knowledge/Skills:
- Excellent written and verbal communication skills.
- Strong organizational abilities.
- A proactive self-starter who collaborates effectively within a multidisciplinary team.
- Ability to motivate patients.
- Basic electronic health record (EHR) skills.
License/Registration/Certification:
- Active Massachusetts medical license.
- DEA license.
- Massachusetts controlled substance license.
- Board eligibility.
- Basic Life Support (BLS) certification within 90 days of employment.
Competencies:
The employee must satisfactorily fulfill all assigned job duties, demonstrating the following:
- Clinical Care: Provides patient care as a member of a multidisciplinary care team, including physicians, mid-level providers, residents, nurses, medical assistants, social workers, nutritionists, and administrative staff, across all primary care clinics. Physicians will have a designated patient panel for whom they and their care team are responsible. While physicians are accountable for their own treatment decisions, they are expected to collaborate closely with the care team to develop both individual patient care plans and a broader systems approach to population health, addressing the needs of their patient panel and subgroups with chronic conditions or other identified high-risk populations.
- Laboratory and Image Review: Reviews and approves all patient laboratory and imaging results. Collaborates with the team to establish systems for following up on abnormal results, communicating normal results, and managing missed or “no-show” lab/imaging appointments.
- Referrals/Transition of Care: Reviews and approves all patient transition of care documentation (ED visits, hospitalizations, referrals). Collaborates with the team to develop systems for following up on outstanding needs, transitional care needs, and managing missed or “no-show” referrals.
- Access: Maintains accessibility for clinical care, both in person as per contract agreement, and via after-hours phone consultation according to the clinic’s rotation schedule.
- Documentation: Clearly documents all clinical interactions (in-person and by phone) in the electronic health record, adhering to health center and clinic documentation workflows, to ensure seamless communication and data collection.
- Patient-Centeredness: Prioritizes patient needs in all treatment plans and broader clinical operations plans, actively involving patients in the development of these plans.
- Community Member/Citizenship: Contributes positively to the work environment and the community.
- Self-Monitoring: Maintains current medical knowledge and ensures professional and courteous interpersonal skills with patients and other clinical staff.
- Team Monitoring: Works with team members to enhance their skills and plans continuing training in clinical and customer service areas. Communicates the overall functioning of the department to the team. Ensures that staff interpersonal skills with patients and providers are always professional and courteous. Ensures that team operations are systematic and efficient. Maintains communication with the clinical director regarding the care team’s performance. Understands the process for communicating team member performance issues to the appropriate administrators.
- Continuous Quality Improvement: Is accountable for individual and team quality measures. Participates in team or department discussions to optimize data documentation and uses data/measurement to design process improvements. Helps develop interventions in current systems/processes to improve outcomes for patients, populations, and clinic operations.
- Participation in Clinic-Specific Projects: Contributes to internal improvement projects, research projects, and grants.
Responsibilities:
- Evaluate and treat patients according to established standards of care.
- Monitor and ensure quality of patient care through data analysis and chart reviews.
- Complete all medical record documentation promptly, collaborating with a quality-based coder to ensure accurate coding.
- Coordinate patient services, including specialty referrals, hospital and skilled nursing facility (SNF) coordination, durable medical equipment, and home health care.
- Participate in daily center huddles.
- Maintain a professional and approachable demeanor.
- Adhere to policies and protocols established by Clinical Leadership.
- Meet with medical directors to discuss quality of care, review outcome data, and address policy, procedure, and record-keeping issues.
- Contribute to potential growth opportunities for new or existing services within the Center.
- Participate in the local primary care “on-call” program as needed.
- Maintain compliance with licensing, certification, and accrediting bodies.
- Dedicate 100% of time to clinically focused activities related to direct patient care, including patient-facing time and general administrative tasks (charting, meetings, etc.) related to direct patient care.
Required Qualifications:
- Graduate of an accredited MD or DO program; successful completion of an accredited ACGME/AOA residency program.
- Board Certification or eligibility for certification (ABMS or AOA) in Family Medicine, Internal Medicine, or Geriatric Medicine.
- Current and unrestricted medical license (or willingness to obtain one) in the state of practice; willingness and ability to obtain licenses in other states within the assigned region, as required.
- Excellent verbal and written communication skills.
- Strong interpersonal and communication skills with colleagues and patients.
- Commitment to the concept of an “integrated team-based care” model.
- Willingness and ability to learn and adapt to practice in a value-based care setting.
- Exceptional patient/customer service skills.
- Basic computer skills, including email and EMR.
- This patient-facing role requires participation in our Tuberculosis (TB) screening program. If selected, you will be required to undergo TB screening.
Preferred Qualifications:
- Active and unrestricted DEA license.
- Medicare & Medicaid Provider Number.
- Bilingual in English/Spanish, with the ability to speak, read, and write fluently in both languages without limitations or assistance.
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