Landmark Health, part of the Optum and UnitedHealth Group family of businesses, 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.
Provides medical care and management to members served by the program and participates in gathering clinical information for medical necessity determinations for service requests. Works with the Landmark Health Medical Director, Director of Health Services, Corporate Director of Health Services, 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 the PCP, and as needed, the health plan Medical Director and other health professionals, to develop members’ goals of care in all phases of long-term care.
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:
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
Catheter insertion and management
Demonstrate appropriate medical judgment and appropriate use of resources with regards to care plans, diagnostic testing and referrals
Develop solid 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
Customer Service - Manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; responds to requests for service and assistance; meets commitments
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
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
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.
Certificates, Licenses, Registrations:
Medical Doctorate or Doctorate of Osteopathy
Board Certified or Board Eligible in Internal Medicine, Geriatrics sub-specialty or Family Practice
Access to reliable transportation; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy
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]
2+ years clinical experience, home-based care desired
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
Knowledge of clinical standards of care
Ability to meet all Landmark Credentialing Requirements
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
Awareness about UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems
Below are the physical requirements which are representative of those that must be met by the employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Regular requirement to sit; use hands to touch, handle or feel
Regular requirement to talk and listen
Occasional requirement to stand; walk and reach with hands and arms
Occasional requirement to lift and/or move up to 10 pounds
Vision abilities include close vision, peripheral vision, depth perception and ability to adjust focus
Ability to travel by plane or car
Work Environment: Below is a description of the work environment that the employee will encounter while performing the essential functions of the job
Noise level is usually moderate
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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