Job Title

Clinical Practice & Patient Management Comprehensive Primary Care: Conduct physical exams, diagnose acute and chronic conditions, and develop longitudinal treatment plans for adult and geriatric patients.Chronic Disease Management: Take the lead on managing "high-touch" patients with complex comorbidities (Diabetes, CKD, CHF, Hypertension) to prevent disease progression.Preventive Care & Wellness: Perform Annual Wellness Visits (AWVs), focusing on preventive screenings, immunizations, and cognitive assessments.Medication Management: Review and reconcile medications to reduce polypharmacy risks and improve adherence, especially for patients transitioning from hospital to home. Value-Based Care (VBC) & Quality Focus Documentation & HCC Coding: Ensure all clinical documentation is thorough and captures the full complexity of the patient's health to support Hierarchical Condition Category (HCC) coding and RAF accuracy.Closing Care Gaps: Proactively identify and close HEDIS and Stars quality gaps during every patient encounter (e.g., ensuring A1c tests, colonoscopies, and bone density scans are completed).Utilization Management: Work to reduce unnecessary ER visits and hospitalizations through same-day "sick" appointments and diligent follow-up.Transition of Care (TOC): Conduct timely post-discharge visits to ensure patients have their medications and follow-up tests, reducing 30-day readmission rates. Collaboration & Communication Interdisciplinary Teamwork: Collaborate daily with the attending Physician, Medical Assistants, and Care Coordinators to execute the patient s care plan.Patient Advocacy: Act as a primary point of contact for patients and their families, providing education on disease processes and self-management.Specialty Coordination: Communicate with specialists to ensure a "closed-loop" referral process, ensuring that specialist recommendations are integrated into the primary care plan.