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