Physician - Skilled nursing facility; SNFist

Physician - Skilled Nursing Facility (SNFist)

Location:

US-MA-Worcester
Job
# Positions: 1
Category:
Physician

About Fallon Health:

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs.

Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

About Summit Elder Care:

Summit Elder Care, offered by Fallon Health, is the only program of its kind in Central Massachusetts and is one of eight PACE programs in the State. Currently there are 124 PACE Organizations nationwide across 31 states operating 255 PACE centers. Summit Elder Care provides a combination of medical, social and insurance services using an interdisciplinary team approach to help older adults avoid nursing home placement.

The program offers outpatient medical care, social day programming, home care and comprehensive insurance coverage with no co-payments or paperwork for participants. Our physicians and nurse practitioners are able to provide care for the frail elder not available in any other setting. Our comprehensive program is not constrained by the usual insurance company rules and benefit limitations and we have the capacity to offer services that are not often covered by other plans.

Brief summary of purpose:
The Summit Elder Care skilled nursing facility physician is responsible for providing high-quality, participant-centered care to patients in skilled nursing facilities (SNFs). He/She will manage medically complex, post-acute and long-term care participants residing in Skilled Nursing Facilities. He/She will be responsible for initial and ongoing care at the assigned SNFs, optimizing participant's health outcomes, in coordination with the SNF and Summit Elder Care Interdisciplinary team.

Clinical care and oversight

• Review and cosign (when required) interdisciplinary documentation to ensure accuracy and regulatory alignment.
• Perform duties including, but not limited, to admission H&P, regulatory required physician visits, medications and treatment plans review, signatures on all orders and progress notes.
• Manage and coordinate treatment for participants with multiple chronic medical problems, acute/arising conditions, and complex medication regimens.
• Lead and oversee all transitions, including hospital to SNF, ensuring timely and effective care.
• Conduct daily or scheduled rounds in assigned skilled nursing facilities (SNFs).
• Collaborate closely with the SNF staff i.e. nursing staff, Director of Nursing, rehab team, etc.
• Coordinate closely with the Summit Elder Care interdisciplinary team members.
• Participate in daily SE IDT meetings and communications as needed to ensure effective, appropriate, and coordinated care.
• Communicate effectively with participants, caregivers, facility staff and SE IDT members regarding patient goals, treatment plans and care transitions.
• Build and sustain trusted relationships with SNF medical directors, Directors of Nursing, and key SNF clinical leaders to enhance care consistency and collaboration between SNFs and Summit Elder Care.
• Maintain a regular, visible presence in each assigned SNF, promoting physician accessibility and adherence to PACE principles.
• Partner with hospitalist, SE primary care provider and other team members, to support smooth transitions of care and reduce hospital admissions and readmissions.
• Collaborate with SE team in meeting related utilization metric and MLR goals.

Regulatory compliance

• Ensure compliance with all CMS physician services requirements for SNFs, including required visit frequency, supervision requirements, medical oversight, and documentation standards.
• When applicable, supervise advanced practitioners following state law and CMS regulations.
• Document all physician visits and orders in compliance with SNF EMR standards and PACE documentation requirements.
• Participate in grievances reviews, when applicable, in collaboration with the SE team.
• Review and cosign (when required) interdisciplinary documentation to ensure accuracy and regulatory alignment.

Other

• Participate in quality improvement initiatives as opportunity arises.

Education:

• Medical degree (MD or DO) from an accredited school of medicine.

License/Certification:

• Active and unrestricted medical license in the state of Massachusetts.
• Board certification in Internal Medicine or Family Medicine.
• Geriatric Medicine board certification preferred.
• Board certification Internal Medicine, Geriatrics or Family Practice preferred.

Experience:

• 2-3 years' experience in post-acute care, long-term…