TRANSITIONAL CARE PHYSICIAN (3157)

VIVANT HEALTH•Sacramento, CA

4d•$300,000 - $325,000•Hybrid

About The Position

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.

Requirements

Minimum 10 years of clinical experience required.
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.
Mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
Mid-level skills using e-mail applications.
Ability to quickly learn and use new software tools.
Ability to work independently as well as in a team environment.
Ability to present self in a professional manner and represent the Company image.

Nice To Haves

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.
Proficiency with Electronic Health Record (HER) systems preferred.

Responsibilities

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.
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.
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.
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.
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.