Physician: House calls in Albany, NY

Landmark Health is a high growth, entrepreneurial, home-based provider team that is transforming healthcare by serving the extensive needs of the most chronically ill in our communities. Physicians lead a multidisciplinary team and serve on the frontlines delivering preventive and urgent medical care in the homes of complex, frail, and vulnerable patients.\
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Through the integration of technology, a highly innovative care delivery model, and multidisciplinary clinical teams, Landmark delivers health management capabilities at scale for the frailest and most clinically complex segments of the population the 3-5% of members that account for 20-30% of all national healthcare expenses annually.\
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JOB DUTIES & RESPONSIBILITIES\
As a Physician, your duties will be to:\
Function as day-to-day clinical leader, providing decision support to nurse practitioners and directing the multidisciplinary team\
Perform 4-6 preventive visits daily to optimize chronic conditions, assess home environment, educate patients and caregivers, and develop proactive care plans\
Perform urgent care visits in the home to avoid unnecessary ED transfers and hospital admissions\
Leverage the support of nurse care manager, behavioral health, social work, pharmacy, and dietician to meet patients medical, biopsychosocial, and financial needs\
In situations where there is no existing PCP for the patient, assume responsibility as PCP to drive care and continuity for patients\
In situations where there is an existing PCP for the patient, help to co-manage the patient with the PCP and serve as an extension of clinical care into the home \
Coordinate with other physicians across the continuum of care, including PCP, hospitalist, and SNF providers to smooth transitions and prevent readmissions\
Coordinate and offer medical direction to community-based organizations touching the lives of our patients, including housing and caregiver agencies, health plan contracted social work services, home health, adult day health centers, and behavioral health \
QUALIFICATIONS\
Board Certified /Preferably Internal Medicine, Family Medicine, or Emergency Medicine\
Doctor of Medicine M.D. or Doctor of Ostepathy D.O. from an accredited educational institution\
DEA registration\
Experience managing complex, polychronic patients and comfort with high acuity\
Dedication to transforming care for the sickest and frailest in a marginalized population\
Eagerness to work with a diverse and multidisciplinary team
Employment Type: Full-Time