Physician - Pace

Position: PHYSICIAN - PACE
Job Purpose

The purpose of this role is to deliver comprehensive in-home and in-center assessments and determine appropriate levels of care for participants, ensuring their needs are accurately identified and addressed. The role involves active participation in quality assurance programs and audits to maintain and enhance service standards. As a key member of the Interdisciplinary Team (IDT), the role is crucial in collaborating with other disciplines to develop and refine individualized care plans, ensuring a coordinated and effective approach to participant care.

Duties and Responsibilities

* Performs an initial comprehensive history and physical assessment on new enrollees, interval assessments on established participants (semi-annually, as condition necessitates or as requested) and documents in the medical record as required.

* Functions as a member of the Interdisciplinary Team (IDT), communicates participant changes to team members, and participates in IDT meetings. Provides updates to the IDT on a regular basis.

* Assists in the development, implementation and evaluation of the participant plan of care as described in policy. Develops care planning goals based on the expressed wishes and preferences of participants within the context of their medical and psychosocial conditions.

* Evaluates and treats participants with episodic illnesses and documents in the medical record as required by policy.

* Provides, promotes, and educates participants and families on health maintenance of their chronic medical conditions and actively participates in family conferences.

* Regulates and adjusts participant medications as needed and in accordance with their changing health conditions. Collaborates with pharmacists, as needed.

* Communicates with attending physicians when participants are hospitalized and advocates for care that is consistent with the participant's expressed wishes and values.

* Coordinates discharge planning with the IDT and hospital discharge planners.

* Manages participant's care if admitted to a skilled nursing facility (SNF). Regularly visits the SNF for participant evaluation. Communicates with SNF staff as requested/required.

* Participates in committees, work groups, and Quality Improvement activities as needed.

* Participates in the coordination of the participant's 24-hour delivery of care services.

* Maintains current accurate documentation of diagnoses, health care services provided, coordinated or contracted.

* Promptly addresses inquiries from medical records staff and coding specialists.

* Collaborates with the Medical Director and Advance Practice Professionals in the provision of medical care.

* Performs home visits, when needed, and participates in a 24-hour on call rotation with other Primary Care Providers.

* Evaluates the effectiveness of the participant's plan of care and revises as appropriate.

* Obtains a complete health history and records the findings in a systematic organized manner.

* Performs physical examinations, orders and evaluates appropriate laboratory and diagnostic tests in a cost-effective manner, and records systematically.

* Performs functional status evaluation and/or mental status examinations using standardized procedures.

* Identifies and describes behavior patterns of the chronically ill.

* Triages status changes in participants and facilitates appropriate management of problem identified.

* Provides preventive health care and health promotion for PACE participants.

* Treats and manages acute chronic illnesses in the day health center, nursing home, group home, or in participants' homes.

* Regulates and adjusts medications as needed and in a cost-effective manner.

* Provides inpatient attending coverage when participant is hospitalized or admitted to a nursing home and communicates participant status the PACE IDT team.

* Works as supervising physician with the nurse practitioner or clinical nurse specialist.

* Functions as a member of the interdisciplinary team and participates in the development of the comprehensive plan of care and ongoing monitoring of the participant's health status, providing geriatric and medical knowledge when needed.

* Maintains current,…