Physician, Post Acute - Institutional Special Needs Plan (Las Vegas, NV)

Job Description

Summary ‎ With nearly 30 years of experience in providing advanced primary care, CareMore Health delivers exceptional patient experiences. Compassionate clinicians take the time to understand each patient’s unique health needs while also removing barriers to access. Patients trust us to receive the right personalized care where and when they need it – in our care centers, at home or virtually – to improve their health outcomes and quality of life. ‎ How will you make an impact & Requirements ‎ Primary Care Physician – ISNP (Institutional Special Needs Plan) Las Vegas, NV The Primary Care Physician (PCP), ISNP is responsible for providing comprehensive, patient-centered primary care to a complex senior population enrolled in CareMore’s Institutional Special Needs Plan (ISNP) program. This role partners closely with an interdisciplinary care team to deliver high-quality, value-based care with a focus on improving clinical outcomes, reducing avoidable hospitalizations, and supporting patients in long-term care (LTC), skilled nursing facilities (SNF), and other institutional settings. The physician provides longitudinal care management, completes timely assessments, coordinates transitions of care, and supports CareMore’s mission of improving the health and well-being of vulnerable populations through proactive and evidence-based care. Key Responsibilities: Clinical Care & Patient Management: Deliver high-quality primary care services to ISNP members with complex chronic conditions in institutional settings (e.g., SNF/LTC). Conduct comprehensive patient assessments, including admission evaluations, routine follow-ups, and acute visits as clinically indicated. Develop and manage individualized care plans, including chronic disease management and preventive care interventions. Provide timely diagnosis and treatment while aligning with evidence-based guidelines and CareMore clinical protocols. Care Coordination & Transitions of Care Coordinate care with nurses, care managers, social workers, specialists, facility staff, and other interdisciplinary team members. Manage transitions of care including post-acute follow-ups, hospital discharges, readmission prevention, and medication reconciliation. Collaborate with patients and families to support care goals, advanced care planning, and health education. Documentation & Compliance Ensure accurate, thorough, and timely documentation in the electronic medical record (EMR). Complete required documentation supporting quality, risk adjustment, and program compliance. Follow all regulatory requirements and internal policies related to CMS, ISNP standards, and institutional care. Quality, Outcomes & Value-Based Care Support achievement of clinical and quality outcomes including preventive screenings, chronic disease measures, and patient experience. Participate in initiatives aimed at reducing avoidable emergency department visits, readmissions, and total cost of care. Contribute to continuous improvement efforts through participation in clinical reviews, team huddles, and process improvement work. Professional Practice & Team Collaboration Demonstrate clinical leadership and act as a trusted partner to the care team and facility partners. Participate in interdisciplinary case conferences, care planning meetings, and clinical operations discussions as needed. Maintain a culture of compassion, respect, accountability, and excellence in patient care. Minimum