Physician, Post Acute - Institutional Special Needs Plan

Location: Nevada

** Job Description Summary
** With nearly 30 years of experience in providing advanced primary care, Care More Health delivers exceptional patient experiences. Compassionate clinicians take the time to understand each patient’s unique health needs while also removing barriers to access. Patients trust us to receive the right personalized care where and when they need it – in our care centers, at home or virtually – to improve their health outcomes and quality of life.

** How will you make an impact & Requirements**#
** Primary Care Physician – ISNP (Institutional Special Needs Plan)
** The Primary Care Physician (PCP), ISNP is responsible for providing comprehensive,  patient-centered primary care to a complex senior population enrolled in Care More’s  
** Institutional Special Needs Plan (ISNP)
** program. This role partners closely with an  interdisciplinary care team to deliver high-quality, value-based care with a focus on  improving clinical outcomes, reducing avoidable hospitalizations, and supporting  patients in
** long-term care (LTC), skilled nursing facilities (SNF), and other  institutional settings**.The physician provides longitudinal care management, completes timely assessments,  coordinates transitions of care, and supports Care More’s mission of improving the  health and well-being of vulnerable populations through proactive and evidence-based  care.#
*
* Key Responsibilities:

**** Clinical Care & Patient Management:
*** Deliver high-quality primary care services to ISNP members with complex
* chronic conditions in institutional settings (e.g., SNF/LTC).
* Conduct comprehensive patient assessments, including admission evaluations,
* routine follow-ups, and acute visits as clinically indicated.
* Develop and manage individualized care plans, including chronic disease
* management and preventive care interventions.
* Provide timely diagnosis and treatment while aligning with evidence-based
* guidelines and Care More clinical protocols.
** Care Coordination & Transitions of Care
*** Coordinate care with nurses, care managers, social workers, specialists, facility
* staff, and other interdisciplinary team members.
* Manage transitions of care including post-acute follow-ups, hospital discharges,
* readmission prevention, and medication reconciliation.
* Collaborate with patients and families to support care goals, advanced care
* planning, and health education.
** Documentation & Compliance
*** Ensure accurate, thorough, and timely documentation in the electronic medical
* record (EMR).
* Complete required documentation supporting quality, risk adjustment, and
* program compliance.
* Follow all regulatory requirements and internal policies related to CMS, ISNP
* standards, and institutional care.
** Quality, Outcomes & Value-Based Care
*** Support achievement of clinical and quality outcomes including preventive
* screenings, chronic disease measures, and patient experience.
* Participate in initiatives aimed at reducing avoidable emergency department
* visits, readmissions, and total cost of care.
* Contribute to continuous improvement efforts through participation in clinical
* reviews, team huddles, and process improvement work.
** Professional Practice & Team Collaboration
*** Demonstrate clinical leadership and act as a trusted partner to the care team and
* facility partners.
* Participate in interdisciplinary case conferences, care planning meetings, and
* clinical operations discussions as needed.
* Maintain a culture of compassion, respect, accountability, and excellence in
* patient care.#
*
* Minimum Qualifications:

*** MD or DO from an accredited medical school.
* Completion of an accredited residency program in Family Medicine, Internal
* Medicine, or Geriatrics (preferred)
* Current, unrestricted medical license in the state of practice (or ability to obtain).
* Board Certified or Board Eligible in Family Medicine or Internal Medicine.
* DEA license#
** Preferred Qualifications
*** 2+ years of experience providing primary care to seniors and/or medically
* complex populations.
* Experience providing care in institutional settings such as Skilled Nursing
* Facilities (SNF), Long-Term Care (LTC), Assisted Living or…