Our Complex Care Team is a group of caring and passionate professionals dedicated to improving the lives of our most vulnerable members. Our team includes physicians, nurses, social workers, medical assistants, behavioral health specialists and others who provide in-home primary care and transitional care services. A goal for this program is to improve our offering of palliative and supportive care services for members with advanced illness.
Our leading complex care offering is the Clover In-Home Care program. This program provides vulnerable members, including those with major complex chronic conditions, frailty, and advanced illness, with in-home primary care services from an interdisciplinary team. Our providers are trained in geriatrics and supportive care and are able to focus on the symptoms and conditions that matter most to complex older adults.
The primary care provider (PCP) is a medical doctor specializing in family medicine, internal medicine, and/or geriatric medicine, and who provides primary care to an assigned panel of patients in accordance with licensure, privileges, and scope of practice.
In collaboration with the Patient Care Team (PCT) composed of nurses, medical assistants, and social workers, the PCP is responsible for the following:
- Assuming primary medical responsibility for their assigned patients.
- Visiting patients at home as well as conducting telehealth visits, where appropriate.
- Providing person-centered care by eliciting patients values and preferences and structuring care plans to reflect these desires.
- Routinely determining patients' prognoses and structuring care plans, including advanced care planning, to reflect these prognoses.
- Routinely determining primary drivers of hospitalization risk and structuring care plans to minimize these risks.
- Achieving high performance on CMS and NCQA-determined Stars and HEDIS quality metrics, respectively.
- Providing care that is consistent with medical evidence, including identified clinical protocols.
- Identifying obstacles to care and medical decision-making and collaborating with the larger PCT to address these obstacles.
- Leading interdisciplinary team (IDT) meetings.
- Ensuring execution of member care plans by the PCT through clinical personnel supervision and education and training.
- Determining the need for consultation from medical, surgical, rehabilitative, and/or psychiatric specialties.
- Determining the need for and facilitating care by an emergency department, hospital, skilled nursing facility, home health agency, hospice and/or community-based organization as appropriate and consistent with patients goals of care.
- Providing medical administrative support such as signing forms requiring physician signature.
- Documenting all clinical encounters in a timely and accurate manner, including in proprietary Clover tools such as Clover Assistant.
- Participating in ongoing professional development and self-improvement.
- Collaborating with the practice Medical Director and Practice Manager in efforts of continuous quality improvement, including that related to the EHR and Clover Assistant .
- Collaborating with the practice Medical Director and Practice Manager in efforts to pilot new care delivery models.
- Supporting Clover efforts to establish a positive image for the In-Home Care practice in the medical community.
You will love this job if:
- You are passionate about caring for our most vulnerable elders, including those with multiple chronic conditions, frailty, and advanced illness.
- You enjoy team-based collaborative care.
- You love developing relationships with your patients and their caregivers.
- You embrace technology and clinical protocols as a means for driving high quality clinical care.
- You are flexible and comfortable working in an evolving environment that values innovation.
- You embrace measurement and performance management to drive improved member outcomes.
You should get in touch if:
- For Physician (PCP) candidates only: You have a MD/DO degree and are Board Certified or Board Eligible in Family, Internal or Geriatric Medicine.
- You have an active license to practice.
- You desire to work full-time or are open to working a minimum of 33 hours a week.
- You have demonstrated clinical competencies in such areas as age-specific care, cultural assessment and health education.
- You enjoy working with patients of diverse social, ethnic, and cultural backgrounds.
- You are comfortable walking up at least 3 flights of stairs as some residences may not have elevators.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.