Senior Primary Care Physician: Complex Chronic Care Lead

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

Job summary

AbsoluteCARE Medical Center & Pharmacy seeks a physician to lead and coordinate care for patients with multiple chronic conditions. You will work with a multidisciplinary team including social work, case management, behavioral health, pharmacy, and nutrition to implement comprehensive plans of care.

The role emphasizes transitional care, discharge planning, and preventing readmissions through evidence-based, PCMH-aligned care.

Qualifications

• Licensed physician in the state of Practice.
• Board certified in Internal Medicine or Family Practice.
• BLS certification required.
• Mission-driven to serve the underserved.
• Ability to work as part of a multidisciplinary team with constant collaboration.

Responsibilities

• Focus on management and improvement of health for patients with multiple complex and chronic conditions.
• Lead a team with social work, case management, behavioral health, pharmacy, nutrition, etc.
• Develop transitional care plans and track paneled patients through hospital discharge to home care.
• Coordinate with hospital, ER, SNF, and other facilities to facilitate appropriate discharge.
• Treat acute exacerbations of chronic conditions within AbsoluteCarecenter.
• Accept same day/next day or urgent appointments for high-need patients.
• Keep vigilant track of patients to prevent ER visits and readmissions.
• Educate patients on chronic disease progression and advanced directives.
• Practice evidence-based medicine within the PCMH model.

Skills

Team leadership

EMR experience

Multidisciplinary collaboration

Problem solving

Education

Board certification: Internal Medicine or Family Practice

BLS certification

Licensed physician in state practice

Tools

EMR systems

Job description

AbsoluteCARE Medical Center & Pharmacy seeks a physician to lead and coordinate care for patients with multiple chronic conditions. You will work with a multidisciplinary team including social work, case management, behavioral health, pharmacy, and nutrition to implement comprehensive plans of care.

The role emphasizes transitional care, discharge planning, and preventing readmissions through evidence-based, PCMH-aligned care.