Physician, Post Acute - Institutional Special Needs Plan

CareMore Health System; Nevada (IA); On-site; USD 211,369 - 317,053; Full time

Job summary

A prominent healthcare provider in Nevada is looking for a Primary Care Physician to deliver comprehensive, patient-centered care to seniors enrolled in an Institutional Special Needs Plan. The successful candidate will coordinate care within interdisciplinary teams and be responsible for patient assessments and chronic disease management. Excellent communication and collaboration skills are essential, along with experience in institutional settings. This role offers a competitive salary and a supportive work environment focused on quality care.

Qualifications

• 2+ years of experience providing primary care to seniors.
• Experience in Skilled Nursing Facilities or Long-Term Care settings.
• Knowledge of Medicare Advantage and HEDIS.

Responsibilities

• Deliver comprehensive primary care services to seniors in institutional settings.
• Coordinate care with multidisciplinary team members.
• Ensure accurate and timely documentation in electronic medical records.

Skills

Patient-centered care

Clinical quality and evidence-based decision making

Strong communication skills

Collaboration in a multidisciplinary care model

Education

MD or DO from an accredited medical school

Board Certified or Board Eligible in Family Medicine or Internal Medicine

Job description

**Job Description Summary**With nearly 30 years of experience in providing advanced primary care, CareMore 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 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.# **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.# **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 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**Compensation:**$211,369.00to$317,053.00At CareMore Health, we provide effective Advanced Primary Care and Palliative Care by seeing the whole person — body, mind, and spirit. We do it with doctors and nurses who provide personalized and compassionate care, nationally recognized disease prevention and management programs, and healthy-living plans. It helps patients get healthier, while receiving the healthcare experience they’ve always wanted.Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. The Business Units which comprise Mosaic Health are multi-payer and serve nearly one million consumers across 19 states, providing them with access to high quality primary care, integrated care teams, personalized navigation, expanded digital access, and specialized services for higher-need populations. Through Mosaic Health, health plans and employers have an even stronger care provider partner that delivers affordability and superior experiences for their members and employees, including value-based primary care capacity integrated with digital patient engagement and navigation. Each of the companies within Mosaic Health provide unique offerings that together promise to improve individuals' health and wellbeing, while helping care providers deliver higher quality care. For more information, please visit www.mosaichealth.com.Mosaic Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.If you require an accommodation for the application or interview process, please let us know and we will work with you to meet your needs. Please contact [e-mail] for assistance.