Complex Adult Care Provider

Erie Family Health Centers is seeking a mission-driven Complex Adult Care Provider, either physician or advanced practice provider, to deliver high quality, comprehensive primary care to our highest acuity adult patients. This role is designed for clinicians with a strong interest and demonstrated expertise in managing medically and socially complex adult patients, coordinating multidisciplinary care, maximizing health maintenance activity completion, maximizing quality measure attainment, and reducing avoidable hospital and emergency department utilization.

This position provides the opportunity to deeply impact the lives of patients with chronic disease burden, multimorbid conditions, and significant care coordination needs. The clinician will manage a dedicated panel of complex patients, as defined by an Epic ED or hospitalization risk score greater than 50%, representing the top 5% of complexity across Erie. These patients tend to be high utilizers of health care resources, either due to complex medical disease, mental health issues, or social drivers of health.

At Erie, we are proud to provide competitive salaries, high-quality health care plans, generous time off benefits, retirement benefits, and more! Erie employees are eligible for Eries Full Benefits Package that includes Medical, Dental, Vision, Life and Disability Insurance and Flexible Spending (FSA) for Health Care or Childcare. Retirement Programs: 401(k) program with Erie matching $0.50 for every $1.00 up to the first 5% of the employees biweekly salary. Annual Paid Time Off: starting at 20 days of PTO, and 8 paid holidays. Competitive salary, annual merit increases, plus room for growth and career advancement.

*This role may be filled by an Advanced Practice Provider or a Physician and compensation will vary depending on licensure, please, see below the appropriate ranges:

Advanced Practice Provider: 110K to 125K

Physician: 175K to 205K

**Compensation will vary depending on specialty and is based on each candidates experience, skills and education within the range identified for the role. Candidates who meet the minimum requirements of the role will start at entry in the range. Any additional skills, experience and education will be reflected in the compensation offered.

Main Duties & Responsibilities

Clinical Care

1) Provide comprehensive, longitudinal primary care to a panel of approximately 550–

750 complex adult patients, depending on clinician template and FTE.

2) Manage chronic and multimorbid conditions with a focus on stabilization, disease

control, prevention of acute exacerbations, and maximizing / restoring function and

longevity.

3) Conduct patient-centered visits that emphasize assessment, education, and care

planning.

4) Provide high-touch, relationship-based care designed to improve quality outcomes

and patient experience.

5) Refers clients to specialists, as necessary. Follows up on and integrates specialist

recommendations into comprehensive care plans and addresses at subsequent PCP

visits.

6) Collaborates with family members and/or patient support as needed/desired by the

patient.

7) Documents all patient care activities per Erie standards.

8) Provide care for patients Monday through Friday except when out of the office on

Paid Time Off, Holidays, or Continuing Medical Education

9) Participate in a fair and equitable share of evening, weekend, and holiday work

Care Coordination

10) Participates in and collaborates with interdisciplinary teams—including care

managers, behavioral health, pharmacy, nursing, and social services—to address

medical, behavioral, and social drivers of health.

11) Develop and oversee individualized care plans aligned with patient goals and

evidence-based standards.

12) Coordinate transitions of care following hospitalizations, emergency department

visits, or specialty referrals.

13) Establish cadence of PCP care based on patients chronic conditions to achieve

desired outcomes.

Utilization Management

14) Apply best practices to reduce unnecessary ED visits, hospital admissions, and

readmissions.

15) Identify and proactively address barriers to care access, adherence, and self-management.

16) Finds creative and innovative ways to connect with hard-to-reach patients to reduce

no-shows and get patients back into care.

Team Engagement

17) Participate in team huddles at the beginning of each clinical session.

18) Serve as a clinical resource and mentor for staff regarding best practices in complex

adult care.

19) Provide advisement when complexity requires PCP transition.

20) Participate in Care Management Conferences for patients on PCP panel as

applicable.

Productivity Expectations

21) Reduced clinic template, compared to standard, to reflect complexity and depth of

visits.

a. Physician template: Target of 9 patients per session (10 scheduled)

b. APP template: Target of 8 patients per session (9 scheduled)

Qualifications

Skills and Knowledge:

Required:

Intermediate computer skills.

Knowledge and experience in caring for complex adult patients.

Customer service skills.

Ability to work both independently and collaboratively.

Cultural competency to work with a diverse patient population.

Commitment to health equity and high-quality care for underserved populations.

Demonstrates above skills in medical documentation as assessed by chart review.

Preferred:

Intermediate proficiency in Microsoft Office a plus.

Bilingual fluency (English/Spanish) is a strongly preferred. (May be required to assist

or work with non-English/Spanish-only speaking patients and/or guests.)

Familiarity with Epic and other risk stratification tools.

Intermediate to advanced skills with Epic Electronic Health Record.

Demonstrated success in quality improvement or interdisciplinary team

collaboration.

0.75 clinical FTE or higher strongly preferred

Experience:

Required:

Three (3) years of experience in healthcare required.

Experience and/or strong interest in:

o Complex adult care

o Chronic disease management

o Multidisciplinary care coordination

o Reducing preventable hospital and ED utilization

Preferred:

Prior experience in community health, population health, or complex care models.

Education/Training:

Required:

MD/DO in Internal Medicine, Family Medicine, or Medicine/Pediatrics OR

Advanced Practice Provider: Adult/Gero Nurse Practitioner or Family Nurse

Practitioner, Family Physician Assistant or Adult Physician Assistant

Active Illinois license (or eligibility), DEA, and board certification/eligibility as

applicable.

Preferred:

Fellowship in geriatrics is a plus

The Erie Advantage Pledge

WORKING TOGETHER FOR WHAT MATTERS MOST

Erie makes a pledge that all current and future employees can feel confident that:

- Our mission, vision, and values unite us.

- Our voices matter.

- We do things well.

- Our inclusive culture promotes balance and belonging.

- We find our career sweet spot at Erie.