Medical Director for Transitional Care - Norfolk

MedCentric - Norfolk, VA

This continually growing, innovative primary care organization's model successfully addresses the need for coordinated and specialized care to manage the health of a geriatric patient population by avoiding preventable and costly health issues and treatments.

The Medical Director, Transitional Care is a local market medical leadership position reporting directly to the Market Chief Medical Officer and focused on leading the market’s care for its members as they transition through environments of care outside of our centers. This talented physician will lead the transitional care team, a cohesive group of health care professionals dedicated to keeping our patients connected to their primary care physicians during episodes of acute hospitalization, post-acute care, and also during periods of increased need at home. The transitional care team may include physicians, nurse practitioners, case managers, and administrative support staff. Key daily activities for team members include continuous communication with primary care physicians and inpatient providers, participation in the market’s case conferences, review of inpatient cases via inpatient courtesy visits and remote EMR review, care coordination, risk assessments, home health care monitoring and review, complex community case management, and home visits for high risk and homebound patients.

The Medical Director, Transitional Care will spend at least half of their time devoted to leading the transitional care team in the activities described above. This position may also have additional duties in the market, depending upon their areas of expertise and the needs of the market.


  • Serves as the primary care physician for a partial panel of our patients.
  • Serves as the hospitalist or skilled nursing facility physician for some of our patients (providing direct care in those facilities)
  • Provides specialty care that falls within the physician’s area of specialty
  • Performs utilization review and management.
  • Participates in Targeted Coverage Time- which is time providing care for patients whose primary care physician is on paid time off or otherwise unavailable.
  • Coaches physicians and other clinicians in support of the overall quality and performance in the market
  • Delivers introductory training for all new practitioners.
  • Helps MCMO with physician meetings, training, and education of PCPs and administrative and support staff.
  • Develops internal training materials and SOPs focused on the clinical development of the team.
  • Participates in team meetings and lead focused clinical discussions in clinic and market wide multidisciplinary meetings.
  • Other duties as assigned and modified at manager’s discretion.


  • This physician will need to possess strong clinical skills in the management of seniors with complex medical needs throughout all environments of care
  • Strong leadership and communication skills, the ability to build relationships with external organizations, and interest in information technology applications in medical settings
  • As leader of a transitional care team, this physician will need to effectively lead and manage the daily activities of the team members
  • Cultivate strong relationships with our primary care physicians, their center based care teams, and other staff
  • Good analytical skills and the ability to manage for results
  • Excellent medical skills
  • Conflict management and resolution skills, and ideally, experience of population risk management or complex chronic disease care management
  • Fluent in English

Posted On: Monday, January 4, 2021

Apply to this job