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.

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.

Primary Responsibilities:

• 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:
  • Medical
  • Social
  • Psychological
  • Financial
  • Caregiver support
  • Environmental safety
• 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
• Wound care
• Dressing changes
• 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.

 Competencies:

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.

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]
• 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.
• Malpractice profile meets Landmark’s risk guidelines.
• 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.

Certificates, Licenses, Registrations:

• Medical Doctorate or Doctorate of Osteopathy required
• Board Certified or Board Eligible in Internal Medicine, Geriatrics sub-specialty or Family Practice
• Current DEA
• 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

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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