We are seeking a mission-driven team player passionate about empowering PACE participants to live the independent lives they deserve. In this role, you'll serve as a vital member of the Interdisciplinary Team (IDT), collaborating to provide holistic care that meets participants' unique needs. You will deliver primary care across various settings—whether at the PACE center, in participants' homes, virtually, or in skilled nursing facilities (SNFs).
Your responsibilities include serving as the primary care provider for a participant panel, making clinical decisions, coordinating care across disciplines, and supporting participants through hospital stays and nursing home transitions. You'll also educate caregivers, manage referrals to specialists, and ensure accurate EMR documentation. As part of a dynamic care model, you’ll take on-call shifts and gain exposure to Value-Based Care strategies, contributing to the organization's growth and participant success.
If you are energized by helping seniors reach their goals, this role is perfect for you!
What does success look like in this role?- Collaborative Care: Serve as an integral member of the Interdisciplinary Team (IDT), completing assessments, participating in care planning, and reviewing Service Determination Requests.
- Primary Care Provider: Deliver direct primary medical care to PACE participants, including history and physical exams. Grow and manage your own participant panel in close collaboration with a complex care RN.
- Clinical Decision Making: Initiate, evaluate, review, and close orders for medications, diagnostic studies, referrals, and treatments to ensure high-quality, patient-centered care.
- Flexible Care Delivery: Provide care where participants need it most, whether in the PACE center, at home, virtually, or in skilled nursing facilities (SNFs).
- Multidisciplinary Coordination: Liaise with IDT members, including behavioral health and pharmacists, to coordinate comprehensive care plans for each participant.
- Hospital Support: Assist participants during hospital stays by overseeing inpatient care management, communicating updates with the IDT, collaborating with specialists, and ensuring safe discharges.
- Nursing Home Care: Support participants during nursing home stays by coordinating care between the IDT and nursing home staff, conducting assessments, and managing safe transitions.
- Education and Guidance: Provide education on medical care to participants, caregivers, and the care team to ensure understanding and confidence in care plans.
- Specialty Care Referrals: Initiate referrals to specialist providers and approve follow-up appointments as needed.
- In-Office Procedures: Perform selected in-office procedures in line with competencies, ensuring participants receive timely care.
- Accurate Documentation: Maintain thorough and timely documentation in the EMR, collaborating with documentation specialists for accurate medical coding.
- After-Hours Care: Take after-hour calls remotely on a rotating schedule, supported by a nurse triage team.
- Value-Based Care Learning: Gain exposure to Value-Based Care strategies and learn how to effectively manage high-need, high-cost populations.
- Contribute to Organizational Growth: Embrace additional opportunities and responsibilities as needed, actively participating in the continued growth and success of the organization.
What does a candidate look like in this role?- Passion for Serving Older Adults: A strong commitment to the mission of providing compassionate care to high-risk seniors and frail older adults.
- Experience with Elderly Populations: At least 1 year of experience caring for frail and elderly populations.
- Communication & Interpersonal Skills: Excellent interpersonal and communication skills, with the ability to engage participants, caregivers, and the interdisciplinary team effectively.
- Independent Leadership & Team Collaboration: Demonstrated ability to lead independently while also thriving in a collaborative, team-based environment.
Education & Training:
- Graduate of an accredited School of Medicine or Osteopathy with 2+ years of clinical experience.
- Successful completion of a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME).
- Master’s Degree or Doctorate Degree.
Licensure & Certification:
- Active, unrestricted MD/DO license in California.
- Board Certification in Internal Medicine or Family Practice (Board Certification in Geriatrics is preferred).
- State CDS Certification and DEA Registration.
- Current CPR certification.
- Language Proficiency: English required, Spanish proficiency is highly preferred.
- Valid Driver’s License: Proof of a valid California driver’s license, personal transportation, a clean driving record, and auto insurance as required by State law.
$220,600 - $262,000 a year
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