The Medical Director, Transitional Care is a local market medical leadership position reporting directly to the Market Chief Medical Officer and focused on leading the markets care for its members as they transition through environments of care outside of our centers. This talented physician will lead the transitional care team, a cohesive group of health care professionals dedicated to keeping our patients connected to their primary care physicians during episodes of acute hospitalization, post-acute care, and also during periods of increased need at home. The transitional care team may include physicians, nurse practitioners, case managers, and administrative support staff. Key daily activities for team members include continuous communication with primary care physicians and inpatient providers, participation in the markets case conferences, review of inpatient cases via inpatient courtesy visits and remote EMR review, care coordination, risk assessments, home health care monitoring and review, complex community case management, and home visits for high risk and homebound patients
The Medical Director, Transitional Care will spend at least half of their time devoted to leading the transitional care team in the activities described above. This position may also have additional duties in the market, depending upon their areas of expertise and the needs of the market.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
- Serves as the primary care physician for a partial panel of our patients.
- Serves as the hospitalist or skilled nursing facility physician for some of our patients (providing direct care in those facilities)
- Provides specialty care that falls within the physicians area of specialty
- Performs utilization review and management.
- Participates in Targeted Coverage Time- which is time providing care for patients whose primary care physician is on paid time off or otherwise unavailable.
- Coaches physicians and other clinicians in support of the overall quality and performance in the market
- Delivers introductory training for all new practitioners.
- Helps MCMO with physician meetings, training, and education of PCPs and administrative and support staff.
- Develops internal training materials and SOPs focused on the clinical development of the ChenMed/JenCare team.
- Participates in team meetings and lead focused clinical discussions in clinic and market wide multidisciplinary meetings.
- Other duties as assigned and modified at managers discretion.
The exact division of time dedicated to different duties will depend on market needs and will be determined by the Market Chief Medical Officer.
MARKERS OF SUCCESS:
- Market sick days/1000 will meet local market goals
- Decreasing 7, 30, and 90-day hospital and SNF readmission rates
- Safely minimized hospital and SNF length of stays
- Market Part A costs will meet local market goals
- Transitional care team is capturing > 95% of inpatient care episodes
- Transitional care team is completing post discharge care plans on > 90% of discharges
- Transitional care team is continuously communicating with primary care physicians and actively participating in markets weekly case conferences
KNOWLEDGE, SKILLS AND ABILITIES:
- This physician will need to possess strong clinical skills in the management of seniors with complex medical needs throughout all environments of care
- Strong leadership and communication skills, the ability to build relationships with external organizations, and interest in information technology applications in medical settings
- As leader of a transitional care team, this physician will need to effectively lead and manage the daily activities of the team members
- Cultivate strong relationships with our primary care physicians, their center based care teams, and other staff
- Good analytical skills and the ability to manage for results
- Excellent medical skills
- Conflict management and resolution skills, and ideally, experience of population risk management or complex chronic disease care management
- Fluent in English