Primary Care Physician — Complex Chronic Care Team Lead

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 180,000 - 240,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy in Baltimore, MD seeks a physician to lead interdisciplinary teams and manage care of patients with complex chronic conditions. You will coordinate transitions from hospital to home and work with hospital, ER, and skilled nursing partners to optimize outcomes.

The role emphasizes evidence-based medicine within the PCMH framework, patient education on disease progression, and proactive management to prevent acute episodes.

Qualifications

• Licensed physician with an MD/DO and state license in Maryland or eligible to practice in Maryland.
• Board certification in Internal Medicine or Family Practice.
• BLS certification required.

Responsibilities

• Lead a multidisciplinary care team (social work, case management, behavioral health, pharmacy, nutrition) to manage complex patients.
• Develop transitional care plans tracking patients across hospital discharge, ER, SNF, and home care.
• Coordinate with hospitals, ERs, and facilities to ensure appropriate discharge or transfer to lower levels of care.
• Manage acute exacerbations of chronic conditions within AbsoluteCare Center and determine when higher level care is needed.
• Accept urgent same-day/next-day appointments to prevent readmissions and ensure symptom resolution.
• Monitor disease progression to reduce ER visits, hospital admissions, and readmissions.
• Apply PCMH model principles and provide evidence-based care.
• Educate patients on chronic disease progression and advanced directives.

Skills

Team collaboration

EMR experience

Problem solving

Patient care management

Education

MD license

Board certified: Internal Medicine or Family Practice

BLS certification

Tools

EMR

Job description

AbsoluteCARE Medical Center & Pharmacy in Baltimore, MD seeks a physician to lead interdisciplinary teams and manage care of patients with complex chronic conditions. You will coordinate transitions from hospital to home and work with hospital, ER, and skilled nursing partners to optimize outcomes.

The role emphasizes evidence-based medicine within the PCMH framework, patient education on disease progression, and proactive management to prevent acute episodes.