Job Description

Job Duties and Responsibilities:

• Provide comprehensive primary care services to adult and senior population within the Medicare Advantage model
• Conduct routine and preventative visits, including annual wellness exams, chronic disease management, and acute care visits
• Order outside diagnostic tests and lab work as needed (blood/urine test, tissue samples, imagery, etc.)
• Develop and implement personalized care plans focused on improving patient outcomes, quality and satisfaction
• Manage patients using a value-based approach, emphasizing prevention, coordinated care, and reduction of avoidable hospitalization
• Collaborate closely with care teams including nurse practitioners, medical assistants, case managers and specialists to insure seamless patient care
• Review and address quality metrics, including HEDIS and STAR measures, to optimize clinical performance and patient outcomes
• Accurately and on a timely basis document encounters and diagnoses in eCW, ensuring complete and compliant coding for risk adjustment
• Participate in multidisciplinary meetings and quality improvement initiatives aimed at enhancing clinical outcomes and patient satisfaction
• Maintain ongoing communication with patients and their families, providing education on disease prevention, medication management and health lifestyle choices

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