TRANSITIONAL CARE PHYSICIAN at VIVANT HEALTH LLC

Job Summary

The Transition Care Physician (Physician) will support medically complex Medicare Advantage, Dual Eligible, and Medi-Cal patients following hospitalization, emergency department visits, skilled nursing facility stays, rehabilitation admissions, and other high-risk transitions of care. This role will support both in person and telehealth services.

The Transitional Care Clinic serves as a specialized extension of Vivant Health's care management, utilization management, quality, and population health programs, focused on reducing avoidable utilization, improving quality outcomes, supporting accurate documentation and risk adjustment, and helping members navigate complex healthcare needs.

The Physician will work closely with Advance Practice Providers (APPs), care managers, social workers, pharmacists, specialists, hospitals, Skilled Nursing Facilities (SNFs), home health agencies, infusion providers, and primary care physicians to stabilize patients during critical transitions and facilitate successful long-term care coordination.

Responsibilities

Clinical Care

• Conduct post-discharge and transitional care visits for high-risk members.
• Evaluate and manage medically complex patients following hospitalization, ED visits, SNF stays, and rehabilitation admissions.
• Provide comprehensive medication reconciliation and medication management.
• Manage acute and chronic conditions during transitional periods.
• Develop and implement individualized care plans.
• Coordinate care with PCPs, specialists, hospitals, home health agencies, infusion providers, and community resources.
• Identify and address barriers to care, medication adherence, and follow-up compliance.
• Support quality, utilization management, and risk adjustment initiatives.

Complex Care Management

• Manage patients requiring:
  • IV antibiotic therapy monitoring.
  • PICC line management and removal.
  • Wound care and dressing changes.
  • Complex medication titration.
  • Post-operative follow-up.
  • Oncology treatment coordination.
  • Advanced heart failure management.
  • COPD and pulmonary disease management.
  • CKD and dialysis coordination.
  • High-risk behavioral health transitions.
• Provide temporary medication management when appropriate while coordinating return to PCP and specialty care.
• Monitor laboratory studies and diagnostic testing necessary for transitional care management.

Physician Leadership

• Provide clinic oversight and clinical leadership for APPs and clinical staff.
• Serve as a clinical resource for complex case reviews.
• Participate in interdisciplinary care conferences.
• Collaborate with Utilization Management, Care Management, Quality, Network Management, and Population Health teams.
• Assist in developing clinical protocols, workflows, and best practices.
• Support provider education efforts and community physician engagement.

Hospital and Specialist Collaboration

• Develop and maintain collaborative relationships with:
  • Hospital case management teams.
  • Discharge planners.
  • Skilled nursing facilities.
  • Home health agencies.
  • Specialty physician groups.
• Participate in periodic meetings with hospitals and community partners to improve transitions of care and reduce avoidable utilization.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Competencies

• Minimum 10 years of clinical experience required.
• Experience managing medically complex adult and geriatric populations preferred.
• Experience working within value-based care, Medicare Advantage, managed care, ACO, IPA, or risk-based environments preferred.
• Strong understanding of transitional care management and care coordination preferred.
• Strong clinical judgment.
• Excellent communication and relationship-building skills.
• Ability to communicate goals of care and advance care planning effectively with patients.
• Ability to work independently while collaborating across multiple disciplines.
• Comfortable managing complex patients in a non-traditional ambulatory setting.
• Commitment to quality improvement and patient-centered care.
• Strong documentation and coding awareness.
• Ability to function effectively within a fast-paced value-based care environment.
• Proficiency with Electronic Health Record (HER) systems preferred.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking and analytical skills.
• Ability to solve complex-level problems with minimal supervision.
• Has the ability to be a leader for the department, shows leadership skills and initiative.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers/members.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need-to-know basis.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• MD or DO degree from an accredited institution.
• Active California Physician license.
• DEA registration.
• CA Board Certified or Board Eligible in Family Medicine (preferred) or Internal Medicine, Hospital Medicine, or Geriatric Medicine, or Emergency Medicine ( with significant post-acute experience) required.

Travel

• The incumbent may travel up to 25% of the time between clinic sites, FQHC partner locations, SNFs and community-based care settings

Supervisor Responsibility

• This position supervises several employees in the Transitional Care Clinic.

Work Environment

This job operates in a professional care clinic environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.