COULD THIS BE YOU

At VillageMD, we are committed to helping patients achieve greater health by delivering the most effective, accessible, and efficient healthcare in the world through partnership with primary care physicians. Our high-risk program offers individualized, evidence-based, multidisciplinary, value-based care to our patients with the greatest needs in the care setting best suited to support their wellbeing including the PCP office, high risk clinics, patient homes, and other settings (e.g., dialysis centers). The high-risk team is dedicated to caring for complex, high-needs patients to improve their quality of life, enable them to live well and age healthfully at home and avoid hospitalizations. Each team member will play an essential, role within the team. As a High-Risk Programs Physician lead you will lead a team of advance practice providers (APPs), social workers, and medical assistants, to improve the quality of life of high-risk, complex patients and their caregivers, enable them to age at home, and reduce costly hospitalizations. This work is critical to VillageMD’s mission to create the best at risk primary care practice on the planet and its vision to help patients achieve greater health by delivering the most effective, accessible, and efficient healthcare in the world.

How You Will Get Things Done:

Team Oversight

• Lead a team caring for complex, value-based care (VBC) patients to include: Advanced Practice Providers, Social Workers, Clinical Pharmacists and Coordinators

• Supervises and deploys team for greatest efficiency (all team members work at top of license), effectiveness (patient outcomes, key performance indicators), and return on investment.

• Accountable for the total comprehensive care of all patients

• Lead team meetings and provide education.

APP Supervision

• Actively manage all aspects of APP care: medical decision making, specialty consults, home health and hospice referrals and review minimum of 5% of APP charts for clinical care (emphasis on medication optimization, palliative care/advance directives) and appropriate HCC/HEDIS exclusion documentation.

• Participate in new APP training including spending time in clinic and participating in house calls while reviewing 100% of charts for the first month of clinical care.

• Review all hospitalizations, ED visits, and lead utilization rounds.

• Be available for APP questions

Direct patient care

• Provide visits in clinic, in the home and virtually to manage complex patients and reduce utilization. Unless unstable, new patients will be seen after APP does initial geriatric and palliative care assessments to afford physician ample clinical information for medical decision making and care plan recommendations.

• Hospital rounding to oversee care (not actively manage) and ensure optimal discharge plans

• Emergency department evaluations for appropriate triaging

• Skilled Nursing Facility rounds to oversee care and facilitate discharge home

Administration

• Work with other high-risk teams and coordinating care.

• Lead palliative care services for the market.

• Serve as liaison between high-risk programs and market physicians.

• Serve as liaison between high-risk programs and market leadership Manage patient and primary care provider complaints.

• Attend monthly national clinical leadership meetings

EXPERIENCE TO DRIVE CHANGE

• Active and Current License for State of Practice, or eligibility to receive necessary licensure

• Internal or Family Medicine board certification

• 3+ years post-residency of clinical experience caring for complex patients with significant palliative and geriatric needs

• Certified in Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS)

• Active registration or eligible to register with the Drug Enforcement Agency (DEA) Active Medicare/Medicaid enrollment or be eligible to enroll

• Comfortable with Electronic Medical Record (EMR) system; Athena preferred

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