In this role, you will be a part of the first clinical leaders overseeing and providing direct services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. In addition to direct care, you will provide clinical oversight and leadership to the clinical staff. Your work, and that of the staff you oversee, will take you out into the field and surrounding community. You will also play an important role in developing proof of concept of our care model and our custom-built care facilitation platform.
As a medical director, you will be responsible for providing medical oversight to the clinical staff, collaborating with our partners, and leading the development of clinical practice guidelines. This includes ensuring appropriate clinical supervision of advanced practice clinicians, spearheading clinical quality and performance improvement initiatives, clinical risk management, achieving practice-level and individual patient quality outcomes, and supporting clinical best practice adoption with specific focus on providing appropriate care to frail elderly patients and furthering the integration of behavioral health and primary care services. You will provide clinical supervision to home-visiting nurse practitioners, physician assistants, and nurses who are managing members with complex physical, cognitive, and behavioral health needs as a part of an interdisciplinary care team. As a participant in your panel’s care team, you will provide clinical support to the care team, including Community Health Partners, who will serve as a member’s main point-of-contact, and leading the development of a personalized Member Action Plan (MAP). Additionally, you will participate in out-of-hours on-call duties, as well as phone availability for triage and case discussion with other clinicians on the care team.
• Provide full-spectrum home-based primary care to a panel of members with complex needs, with an emphasis on chronic disease management, primary behavioral health and primary palliative care
• Interface with partner PCPs, specialists, hospitals, and community based organizations to promote an understanding of Cityblock’s model, facilitate collaboration, and promote effective patient co-management
• Provide clinical oversight and supervision for advanced practice clinicians assigned to members in the Waterbury, Connecticut community
• Foster lasting and trusting relationships with members and their family members, to assist members in achieving their goals, identifying new needs, and coordinating care.
• Play a lead role in monitoring, evaluation, and quality improvement activities, including review of member and care team quality of care concerns.
• Drive program development and integration of clinical innovations, including community medicine, care transitions, palliative care, and others.
• Participate in the development and delivery of educational content around complex care delivery, geriatrics and palliative care, chronic disease management, and integration of primary and behavioral health needs.
• Assist in training and mentoring new employees as needed.
• Participate equally in all call responsibilities.
• Go above and beyond to connect with patients and partners in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day.
• Work daily within our custom-built care facilitation platform, Commons, which will enable you to collect data, organize information, track tasks, and communicate with staff, patients, and family. This platform is built for a mobile workforce, and you will field-test our technology, provide feedback to the product development team, and, over time, become part of a super-user group to assist in on-boarding and supporting others.
• Attend external meetings and activities, and maintains professional credentialing and CME standards.