Physician/APRN for Internal/Family Medicine

Washington D.C.
Mar 09, 2017
Apr 13, 2017
Full Time

Community Connections, the largest private non-profit, outpatient behavioral health agency in Washington DC, is hiring a Physician/APRN for Internal/Family Medicine to join its Integrated Health Home Team.  The Health Home Team focuses on improving the overall health of adults with serious mental illness.  The Physician/APRN for Internal/Family Medicine is one member of the integrated care team made up of nurse care managers, social workers, and care coordinators. Responsibilities - Develop a person-centered plan for each individual in collaboration with Nurse Care Manager - Coordinate with an individual's PCP via protocols for disease management in order to improve self management of chronic illness. - Identify and implement best practices within the team to support chronic disease management - Link an individual with a PCP and specialty health services - Participate in comprehensive transitional care between primary care and hospital treatment team during and after inpatient or ER episode - Assess for readmission risk post hospitalization and work with integrated team and PCP to reduce risk and prevent readmission - Implement individual and group health promotion activities - Establish a continuous quality improvement program with Director of Health Homes - Collect, monitor, and review outcomes associated with management of chronic illness to improve population health management - Develop and maintain collaborative relationships with hospitals, primary care, and specialty clinics to enhance coordination of care - Collaborate with individuals' psychiatrists to promote integration of behavioral health and primary care treatment goals and medications - Complete documentation as required utilizing electronic medical records Qualifications MD or APRN licensed to practice in the District of Columbia Experience in a primary care setting Experience working with adults who have serious mental illness Population Health Management experience Interest in working in an integrated team model in a community based setting

Similar jobs