Physician, Medical Doctor, Internal Medicine Physician

Gary and Mary West PACE is a non‑profit that delivers medical, social, and behavioral services to the frail elderly in the North County of San Diego.

Under the supervision of the Medical Director, the PACE Physician provides assessment, planning, primary care, and continuous medical coverage to PACE participants in an interdisciplinary team environment and in accordance with Gary and Mary West PACE standards.

• Provide complex primary care and acute illness evaluation and treatment for participants on an as needed basis via in person, at home or telehealth visits.
• Perform in-person comprehensive assessments on participants and coordinate with the IDT to develop a comprehensive care plan for an assigned participant panel of up to 110 participants.
• Be an active member of the IDT communicating participant changes, collaborating on care planning decisions and patient centered care in line with West PACE mission.
• Work collaboratively with case management RN's and other members of IDT to provide clinical input and care coordination in Transitions of Care scenarios and participate in facility and family care conferences as needed.
• Conduct post hospital and post ED discharge visits within 1 week of discharge as well as acute visits focused on ED and hospital utilization reduction for high risk patients.
• Provide clinical guidance and support to Nurse Practitioners and Physician Assistants. Supervising NP's and PA's may be required.
• Along with the Medical director, serve as a liaison outpatient and inpatient specialist to communicate and improve care for PACE participants.
• Participate in every 5-6 week rotating telephonic only nights and weekends.
• Provide home or SNF visits as needed based on clinical criteria and/or by Gary and Mary West PACE's standards and participants needs.
• At the direction of the Medical Director, review outcomes, coding and utilization data, including review of necessity of hospitalizations and use of specialists; establish best practices with the Medical Director, and collaborate with clinical staff, Community-Based PACE Physicians, and IDT to make policy and procedural improvements to reduce unnecessary utilization and improve participant health.
• At the direction of the Medical Director, special projects may be assigned to help improve care and experiences at West PACE.
• Protect privacy and maintain confidentiality of all company procedures and information about employees, participants and families.
• Follow Gary and Mary West PACE policies and procedures and participate in any required QI activities, staff training and meetings.
• Maintain professional licensure and certifications.
• Act only within the scope of practice.

• Successful completion of a residency program accredited by the Accreditation Council for Graduate Medical Education.
• MD or DO degree.
• Board Certification - Internal Medicine or Family Practice.
• Additional certifications in Geriatrics, Hospice and Palliative Care, Addiction Medicine or Pain is desirable but not required.
• Active CA physician license without restrictions.
• Hospital privileges highly encouraged.
• Current Basic Life Support (BLS) training.
• State CDS Certification and DEA Registration.
• Current driver's license and proof of auto insurance.

• Current knowledge of chronic care/geriatric issues and best practices.
• Current medical knowledge of behavioral health and substance use management.
• Interest or experience in post-acute care or transitions of care role.
• Work well in a managed care environment with an interdisciplinary team (IDT).
• Ability to build strong and collegial working relationships with other providers and care.
• Creative and enthusiastic commitment to the "triple aim" - dedication to improving experience, health, and value for PACE participants.
• Interest or experience in community-based healthcare interventions aimed at keeping high risk seniors in the home setting while providing patient centered care.
• Critical thinking skills required to demonstrate care with participants and utilization of services.
• Excellent clinical, organizational, and communication skills in settings with frail, elderly…