Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for- service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health, and other employed team members. Join Landmark to be part of a growing company full of purpose-driven, action-oriented, and compassionate team members working to dramatically transform healthcare for our communities
OBJECTIVE Provides medical care and management to members served by Landmark Health. Works with the Regional Medical Director, Director of Health Services, Health Plan representatives, and UM staff in the development and/or implementation of medical management policy, clinical protocols, utilization management guidelines, and quality management programs. Dedicated to improving the health and well-being of members; this position collaborates with existing PCPs if present, the Landmark multi-disciplinary team, the health plan Medical Director, and other health professionals, to develop members’ goals of care in all phases of longitudinal.
Functions as the day to day clinical leader of the multi-disciplinary team, providing decision support to team members providing care in the home to Landmark patients
In situations where there is no existing PCP for the patient, the Landmark Physician will assume responsibility as PCP to drive care and continuity for this patient
In situations where there is an existing PCP for the patient, the Landmark Physician helps to co-manage the patient with the PCP and functions as their extension into the home – the PCP’s eye and ears in the home
Assess patients’ needs in their place of residence, including:
Provide 24/7 medical coverage for assigned and covered patients (this can be as part of a call schedule).
Develop and update care plans and documentation of clinical encounters in the electronic medical
record as per Landmark’s Medical Records Policies.
Provide same-day clinical assessment and treatment for pre-crisis intervention.
Participates in management meetings that include, but may not be limited to:
Weekly case conference reviews
Monthly staff meetings
Schedule Joint Operating Committee meetings
Quarterly Quality Improvement Committee meetings
Continuing education/journal club programs
Performs an initial comprehensive assessment on all newly enrolled members and at least annually thereafter. Develops a member management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with members and/or their legal representatives to review newly developed or modified care plans; involves the PCP in these meetings.
Calls and communicates directly with patient’s PCP in real time to discuss any changes of condition and potential medication changes. Plans will be collaboratively decided on with PCP, but if unable to reach and emergent situation, NP/PA will render appropriate services and communicate changes at first available opportunity.
Completes follow-up and post-hospital assessments according to documented standard operating procedure.
Prescribes appropriate diagnostics and interventions to avoid unnecessary transfers/acute admissions.
Consults with hospital physicians following notification of member transfer.
Collaborates with UM staff and PCPs/facility staff to enable medical necessity determinations for requested medical services.
Educates members and/or their legal representatives in disease processes affecting members and ways to manage them effectively, as well as to promote wellness.
Addresses and documents advanced care planning and advanced directive wishes on initial visit and at least annually thereafter
Implements HEDIS measure campaigns and other quality initiatives as directed by Regional Medical Director to ensure the highest standards of care and to promote the improvement of care management and delivery.
Routine caseload during business hours and scheduled on call after hours / weekends with possibility of home visits for crisis interventions.
Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews.
In addition to routine history and physical exam in the home, will be trained and be proficient at such modalities including, but not limited to:
Insertion of IV
Venipuncture for blood draw
Catheter insertion and management
Demonstrate appropriate medical judgment and appropriate use of resources with regards to care plans, diagnostic testing and referrals
Develop strong patient-doctor and caretaker/family-doctor relationships so as to improve patient compliance with care plan
Work with the NCM to ensure care plan is meeting the clinical and psycho-social needs of the patient
Provide timely, evidence-based and appropriate patient care at all times
Complete and sign all documentation (including from vendors) within required timeframes
Maintain high levels of patient and family satisfaction
Arrange for transfers and placements to appropriate levels of care
Perform other duties as assigned
COMPETENCY To perform the job successfully, an individual should demonstrate the following competencies: Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics. Technical Skills - Assesses own strengths and weaknesses; pursues training and development opportunities; strives to continuously build knowledge and skills; shares expertise with others. Interpersonal Skills - Focuses on solving conflict; maintains confidentiality; listens to others; keeps emotions under control and overcomes resistance when necessary; remains open to new ideas. Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and seeks clarification; responds openly to questions. Must be able to deal with frequent change, delays, or unexpected events. Attendance/Punctuality - Is consistently at work and on time; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time. Initiative - Volunteers readily; undertakes self-development activities; seeks increased responsibilities; takes independent actions and calculated risks; looks for and takes advantage of opportunities; asks for and offers help when needed; generates suggestions for improving work and workflow.
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience:
Current, valid, non-sanctioned, non-restricted license to practice medicine in the state
Board Certified in Internal Medicine, Geriatrics sub-specialty or Family Practice [Board Eligible for up to one year if new grad]
Certificates, Licenses, Registrations:
Medical Doctorate or Doctorate of Osteopathy required
Board Certified or Board Eligible in Internal Medicine, Geriatrics sub-specialty or Family Practice
Ability to meet all Landmark Credentialing Requirements
Extensive experience in providing medical care to geriatrics patients
Familiarity with Medicare Guidelines
Familiarity with CPT and ICD-9 codes as related to billing practices.
Minimum of two (2) years clinical experience, home-based care desired.
Knowledge of clinical standards of care.
Awareness about UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems is helpful.
Access to reliable transportation required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
Below are the physical requirements which are representative of those that must be met by the employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Regular requirement to sit; use hands to touch, handle or feel.
Regular requirement to talk and listen.
Occasional requirement to stand; walk and reach with hands and arms
Occasional requirement to lift and/or move up to 10 pounds.
Vision abilities include close vision, peripheral vision, depth perception and ability to adjust focus.
Ability to travel by plane or car
WORK ENVIRONMENT Below is a description of the work environment that the employee will encounter while performing the essential functions of the job.
Noise level is usually moderate
ACKNOWLEDGEMENT I have read the position description on the preceding pages and I understand the requirements of the role. I have the ability to perform all of the functions listed, or have advised management of any reasonable accommodations that need to be made. I understand that this acknowledgement is not to be constructed as an employment contract of any duration.
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
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