Transitional Care Coordinator Jobs in Decatur, GA

We're unique. You should be, too.
We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?
We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.
ChenMed, a physician-led and mission-driven, primary care organization, is currently one of the most successful full-risk Medicare Advantage providers in the nation and has a vision to be America's leading primary care provider, transforming care of the neediest population. Our mission is to honor seniors with affordable VIP care that delivers better health. In order to achieve our vision and deliver our mission, we need the best primary care providers that are seeking to fulfill purpose and personal opportunity and join the ChenMed family.
The Primary Care Physician (PCP) in our organization demonstrates:
• Accountability for outcomes: The PCP demonstrates accountability for outcomes, strong clinical care, and cost-effectiveness for each patient in their panel of up to 450 patients. They understand that they can strongly influence the patient's outcomes by building a trusting relationship and helping them change behaviors.
• Coaching for health: The PCP acts as a health coach, rather than just a consultant for sickness, by helping patients set short and long-term health goals, partners with the patient to work toward the goals, and frequently follows up on those goals on the path to improved health for their patients.
• Simplifying for action: The PCP simplifies and prioritizes appropriately so that behavior change is more actionable, both for the patient in helping them achieve their goals, and when leading their care teams towards their performance goals.
We are an outcomes-focused, value-based organization and for their panel of patients, the following metrics are regularly measured to help PCP's become successful and reach partnership status: patient admissions/thousand, using between 18-21 appointment slots per day (each new patient count for 2 slots, follow-up patients 1 slot), CGCAHPS (patient experience), clinical gaps closures, and medical cost measures. Each PCP will have goals for these metrics and will be expected to work towards those targets with their center and market leadership as well as their care teams. Culture is very important in the medical centers and because PCP's are leaders in our organization and centers, they are expected to help champion a positive culture of love, accountability, and passion along with center leadership.
The PCP will be required to demonstrate the ability to function both independently and in collaboration with other health care professionals. The PCP will work closely with the applicable managers and medical directors to ensure compliance with guidelines along with participating in risk and quality management programs, clinical meetings and other meetings as required that promote patient health and company goals.
The PCP will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.
ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• The PCP independently provides care for patients with acute and chronic illnesses encountered in the older adult patient.
• The PCP will take full accountability for patient care and outcomes and will appropriately seek consultation from specialists when needed, though will still stay involved in, and be responsible for, the detailed care of the patient.
• It is expected that the PCP will engage with the hospitalist whenever one of their patients is in the hospital (regardless of whether the hospitalist works for ChenMed or not).
• The PCP is responsible for assessment, diagnosis, treatment, management, education, health promotion and care coordination and documentation for patients with acute and complex chronic health needs.
• The PCP leads their care team consisting of care promoter (medical assistant), care facilitator, and care coordinator for patients able to come to the office.
• For patients that are unable to come to the office-in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care physicians, and other resources that may be available depending on the market.
• PCP will have an active role in the management of their center and will help cover for other providers who may be out for various reasons. It is also expected that each PCP will take an active role as needed in recruiting patients for the center and additional providers for the company.
• Supervises, collaborates with, participates with, or functions within a practice or collaborative agreement with an Advanced Practice Practitioner (APP) and remains accountable for the actions of the APP while employed with the company.
• Performs other duties as assigned and modified at manager's discretion.

KNOWLEDGE, SKILLS & ABILITIES:
Competencies for Success

• Availability and Accessibility for patients to build trust from their patients. It is expected that PCP's will make themselves as available to their patients as possible by being open and available for walk-in visits and answering phone calls and messages in a timely manner.
• Service Orientation - PCP's provide care that they would want for a family member or for themselves to each patient at every interaction.
• Evidence Based Medicine - The PCP remains updated on evidence-based medicine, but also recognizes that factors outside of traditional medicine, like lifestyle and nutrition, have a large impact on patient health outcomes. The PCP stays up to date on clinical, nutritional, and lifestyle-based interventions to improve outcomes.
• Physician Leadership is integral to good healthcare, so the PCP must be willing to continuously work to develop and improve leadership skills for the benefit of one's patients, their team, their center and the company
• Quality - Our patients deserve the highest quality of care. This requires a willingness to work with the care teams towards achieving high quality outcomes and quality measures. At the same time, PCPs will always be looking for ways to continuously and systematically improve their practice of medicine and the operations of their center.
• Influence - PCP's must competently and compassionately influence their patients, their teams, and themselves to achieve the best outcomes.
• Self-Care - A PCP can take the best care for their patients when they are adequately caring for themselves. That means physically, mentally, socially and spiritually. Physician wellness is important for sustainability and promoting the health of physicians, staff, and patients.
• Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software as used in the company
• Ability and willingness to travel locally as needed in their market, if applicable, nationally for initial training (2 weeks) and then occasionally regionally and nationally for recruiting or training purposes.
• Fluency in English, verbal and written. There may be jobs in some centers that require fluency in other languages, and this will be made known at the time of application.
• This job requires use and exercise of independent judgment
• Flexible to work evening, weekends and/or holidays as needed

EDUCATION AND EXPERIENCE CRITERIA:

• MD or DO in Internal Medicine, Family Medicine, Geriatrics or similar specialty required
• Must be able to obtain a State Medical License or already have a current, active State Medical License for the state(s) in which he/she will be working
• Board certification in Internal Medicine, Family Medicine, Geriatrics or similar specialty is preferred. Board Eligibility is required
• Once Board certified, PCP will maintain board certification in their specialty by doing necessary MOC, CME and/or retaking board exams as required
• Must have a current DEA number for schedule II-V controlled substances
• Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment.

PAY RANGE:
$221,141 - $315,915 Salary
The posted pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for a bonuses or commissions.
EMPLOYEE BENEFITS
https://chenmed.makeityoursource.com/helpful-documents
We're ChenMed and we're transforming healthcare for seniors and changing America's healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We're growing rapidly as we seek to rescue more and more seniors from inadequate health care.
ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people's lives every single day.
Current employees, if you want to apply to our internal career site, please click HERE
Current Contingent Worker please see job aid HERE to apply
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