- Consistently exhibits behavior and communication skills that demonstrates Tandigm’s commitment to superior customer service, including quality, care and concern with each internal and external customer.
- Embraces and exemplifies the core values of Tandigm.
- Promotes high quality care as the most important Tandigm objective.
- Organize, attend and facilitate in all daily Care Team Meetings within the assigned facility.
- Ensure proper progress on plan of care and identify any early warning signs for readmissions during the critical, immediate post-discharge period.
- Discuss goals of care, transition planning, and advanced directives, as appropriate, with patient and families.
- Coordinate appointment for evaluation by specialist as needed for member during their stay at the SNF.
- Responsible for ensuring safe discharge to home from the Skilled Nursing Facilities.
- Provide a true continuum of care to our patients alongside our facility partners.
- Assess alignment of patient care goals with care provided by SNF staff, identify systems barriers, and escalate issues when appropriate.
- Anticipate and plan for needs between visits, including potential discharge planning.
- Timely documentation, discharge summaries, medicine reconciliation, etc. in EMR.
- Participate in SNF & Tandigm meetings, as appropriate.
- Oversees Nurse Practitioners providing care services in Skilled Nursing Facilities.
- Attend and participate in all QI, Peer Review and Care Management Meetings requested.
- Meet all facility requirements and bylaws for Medical Staff.
- Meet communication standards for information transfer to primary care providers for each episode of care provided.
- Meet coding and encounter data standards for completeness, accuracy, timeliness, and reimbersement level.
- Uses, protects, and discloses Tandigm patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned
- Ability and means to travel on a flexible schedule as needed, proof of currently liability & property damage insurance vehicle;
- Travel between Skilled Nursing Facilities daily;
- Maintain and manage a panel of approximately eight patients on a daily basis and must be on-call one day per week and one weekend/month.
Education & Experience
- Licensed Physician in the State of Pennsylvania. License shall be active and free of any limitations or medical board actions;
- Board Certified in Internal Medicine, Family Practice or Geriatric Medicine with minimum of three (3+) years of experience working with Geriatric population. Clinical Practice experience for minimum of 5 years preferred.
- Obtain and maintain all at all assigned skilled nursing facilities;
- Ability to work weekends/be able to be on-call.