Primary Care Physician – Compass PLUS Program
About The Position
Compass PLUS is a home and community-based care management program for the patients with the highest complexity and hospital utilization in the Mass General Brigham MassHealth Accountable Care Organization (ACO). All participants receive clinical and support from a multi-disciplinary care team. The Compass PLUS Primary Care Physician (PCP) is responsible for the care of a small panel of highly complex patients in the Compass PLUS program. Patients who see the Compass PLUS PCP typically have difficulty engaging in office-based primary care or are hospitalized too frequently to attend outpatient visits. Compass PLUS supports the highest-risk patients in the Mass General Brigham (MGB) Medicaid Accountable Care Organization (ACO), addressing clinical complexity and social determinants of health through a high-touch, collaborative care model. The program delivers intensive, wraparound support through geographically aligned care teams that include a Nurse Practitioner, Nurse, Behavioral Health Clinician, and Community Health Worker. For a subset of patients with the greatest needs, primary care may transition fully to the Compass PLUS physician, with the goal of reintegrating patients into traditional primary care settings in the future when appropriate. The Compass PLUS Physician will manage a panel of approximately 100 medically and socially complex patients, in the MGB Medicaid ACO serving as the PCP of record for those receiving primary care through Compass PLUS while also acting as a consultant for other patients in the program receiving wrap-around services. Compass PLUS delivers care mainly in homes and communities, allowing them to address obstacles and reach patients directly. The PCP will also have clinic space available to see patients in an office setting when needed.
Requirements
- MD or DO in Internal Medicine or Family Medicine
- Board certified or board eligible
- Minimum 3 years of primary care experience managing a patient panel
- Eligible for Massachusetts medical licensure and DEA
- Interest in population health and health equity
- Demonstrated success in collaborative care environments
- Comfortable working independently across multiple care settings
Nice To Haves
- Experience caring for patients with complex chronic conditions, behavioral health needs, and/or substance use disorders preferred
Responsibilities
- Provide comprehensive primary care to a panel of high-acuity patients
- Collaborate closely with geographically aligned multidisciplinary care teams
- Develop and implement individualized care plans addressing medical, behavioral, and social needs
- Serve as a consultant to PCPs and care teams managing complex patients
- Support care transitions across inpatient, emergency, and outpatient settings
- Partner with patients and teams to improve outcomes and reduce avoidable utilization
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Ph.D. or professional degree
Number of Employees
5,001-10,000 employees
