The physician conducts brief initial telehealth assessments for older adults and clinically complex members, with a focus on identifying medical needs, risks, and barriers to care after hospital discharge or during care transitions. The visit establishes prioritized clinical goals and a plan for the broader team to carry forward over months of support. This is a relationship-driven, whole-person care model that emphasizes coordination with community health workers, social workers, and care navigators.
Key Responsibilities
- Conduct comprehensive initial telehealth visits for newly enrolled members
- Synthesize complex medical and social histories to identify priorities, risks, and barriers
- Create concise clinical plans and handoffs for community health workers, LCSWs, and care navigators
- Document findings and recommendations in the EMR to guide ongoing care
- Provide clinical guidance on escalation pathways and pilot workflows
- Build rapport quickly with members and caregivers
Required
- MD or DO with an active, unrestricted medical license
- Board-certified or board-eligible in Family Medicine, Internal Medicine, Geriatrics, or a related primary care specialty
- Experience with Medicare/Medicaid populations or complex chronic disease management
- Ability to perform telehealth assessments and build rapport virtually
- Strong clinical judgment and comfort working in a pilot or startup-like environment
Preferred
- Bilingual skills
Benefits & Perks
- 1099 independent contractor status
- Competitive hourly or visit-based compensation, commensurate with experience
- Part-time, flexible scheduling
- Fully virtual visits and EMR documentation
- Opportunity to help shape an early-stage pilot as it scales
- Team-based support from care managers and community teammates