We are seeking a mission-driven Telehealth Primary Care Physician to provide remote medical consultations and ongoing clinical support for patients across post-acute, long-term care, and complex care settings. This role focuses on proactive chronic disease management, timely intervention, care coordination, and reducing avoidable hospitalizations and readmissions.
The ideal candidate is comfortable practicing in a telemedicine environment, has strong clinical judgment, and is experienced in Transitional Care Management (TCM).
Provide remote patient consultations and follow-up care via telehealth
Evaluate patients, develop treatment plans, and ensure timely clinical follow-up
Perform Transitional Care Management (TCM), including post-discharge follow-up, medication reconciliation, and coordination of care
Manage chronic and complex medical conditions through evidence-based virtual care
Collaborate with NPs/APPs, nursing staff, care coordinators, rehabilitation teams, and other providers
Respond promptly to changes in patient condition and help prevent avoidable hospital transfers and readmissions
Participate in interdisciplinary care planning and case review
Discuss goals of care, preventive care, and palliative care options with patients and families as appropriate
Maintain accurate, timely documentation in the EMR
Support continuity of care through strong communication with patients, families, and clinical teams
MD or DO from an accredited medical school
Board Certified or Board Eligible in Internal Medicine, Family Medicine, or Geriatrics
Active, unrestricted medical license in [State] or eligibility to obtain
Current DEA registration, as applicable
Experience with telehealth/virtual care
Familiarity with or experience in Transitional Care Management (TCM) required
Experience in primary care, geriatrics, post-acute care, long-term care, or complex care management preferred
Proficiency with EMR systems and telehealth platforms
Strong communication, clinical decision-making, and care coordination skills
Experience managing medically complex adult or geriatric patients
Experience working with interdisciplinary care teams
Comfort discussing goals of care and advanced care planning
Strong documentation and organizational skills
Patient-centered and compassionate
Confident making clinical decisions in a remote care environment
Proactive, responsive, and detail-oriented
Comfortable collaborating with both remote and on-site care teams
Committed to improving outcomes and supporting care transitions
