Job Description Summary

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The Primary Care Physician (PCP), ISNP is responsible for providing comprehensive, patient-centered primary care to a complex senior population enrolled in CareMore’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 CareMore’s mission of improving the health and well-being of vulnerable populations through proactive and evidence-based care.

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How will you make an impact & Requirements

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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 CareMore 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.
• Possible hospital rounding once every two months.

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.
• Active DEA license
• BLS certification
• Completion of all required health screenings (TB test must be within the last 12 months)
• Hep B Vaccination (all 3 doses, titer or signed declination)

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 post-acute environments
• Knowledge of value-based care models, Medicare Advantage, HEDIS, Stars, and risk adjustment/HCC documentation.
• Comfort working collaboratively in a multidisciplinary care model.
• Strong communication and relationship-building skills with patients, families, and facility partners.

Work Environment & Physical Requirements

• Primarily facility-based and/or field-based in institutional settings.
• May require travel between assigned facilities and/or CareMore locations.
• Ability to sit, stand, and walk throughout the workday and perform required patient assessments.
• Ability to work with standard office and clinical equipment.

Core Competencies

• Patient-centered care with a commitment to service excellence
• Clinical quality and evidence-based decision making
• Strong collaboration and interdisciplinary teamwork
• Accountability and integrity
• Efficient documentation and attention to detail
• Adaptability in a fast-paced healthcare environment

Cidalia Fidalgo
Provider Recruiter

c: 239-218-1011

e: cidalia.fidalgo@mpgus.com

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Compensation:

$211,369.00

to

$317,053.00