PACE Primary Care Practitioner; PCP

The PACE Primary Care Practitioner (PCP) is a progressive, population-based health role that provides exceptional quality participant care. The PACE PCP is responsible for coordinating all services, including evaluation, treatment, coordination with specialists, health education, and executing Age-Friendly care. This position requires excellent clinical skills across all aspects of medicine, exceptional collaboration capabilities, and proficiency in working with an interdisciplinary team (IDT).

This role champions the PACE model of care across the continuum and understands that medical decision-making is done in the context of overall goals of care.

• Provide and manage direct participant care, including physical examinations, evaluations, assessments, diagnoses, treatment, and care planning.
• Perform basic office-based, ambulatory procedures.
• Participate in tele-health/virtual health practices as indicated.
• Provide Age-Friendly and goal-concordant participant care.
• Engage in Advance Care Planning (ACP) and palliative approaches to participants in the context of goal-concordant care.
• Complete and sign reports of death in compliance with state law.
• Actively participate as a member of the PACE IDT to develop and implement a comprehensive plan of care for each participant upon enrollment and throughout their enrollment as specified by PACE regulations.
• Collaborate closely with the PACE Nursing team in delivering care within the clinic and at participants’ homes.
• Ensure clear and accurate documentation within the Electronic Health Record (EHR), including all communication and decision-making as specified by PACE regulations.
• Advise on care management and examine patients with other PACE PCPs, including physicians, Nurse Practitioners, and Physician Associates (PA), as indicated.
• Collaborate with specialists, including dentistry, podiatry, chiropractic, therapies (speech, physical, occupational), and medical subspecialties.
• Coordinate care across all settings, including hospitals, skilled nursing facilities, and assisted living facilities, and closely collaborate with other attending physicians.
• Visit participants in their homes or care settings as indicated.
• Fulfill all administrative duties on a timely basis, including record-keeping in participant charts and appropriate and medically necessary diagnosis coding.
• Conduct timely peer-to-peer discussions to clarify clinical information and explain review outcome decisions across the continuum of care.
• Prescribe pharmaceuticals and treatment regimens as appropriate to assessed medical conditions.
• Refer to and coordinate with specialists as appropriate.
• Serve on various internal and external committees as required or designated.
• Provide all services in a manner consistent with Pacific Source core values and State and Federal regulatory requirements.
• Participate in team meetings, caregiver groups, and special events as indicated.
• Provide on-call coverage for direct patient care after hours and on weekends as indicated.
• Foster a safe and supportive environment conducive to the professional development of healthcare professionals.

• Meet department and company performance and attendance expectations.
• Follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

A minimum of 1 year of experience working with a frail or elderly population is required. Additionally, 5 years of nursing or varied healthcare exposure and experience are necessary. Experience in a value-based healthcare organization, payer model, or a closely related field is preferred. Prior experience in PACE, skilled nursing, or a managed Medicaid setting is preferred.

CPR certification (BLS or ACLS) is required. A current and valid Drug Enforcement Agency (DEA) certificate and a valid Oregon driver’s license are also required.

A valid, unrestricted license as an independent Oregon-licensed Nurse Practitioner (NP) with the Oregon State Board of Nursing (OSBN) is required. An active Oregon RN license (a legal…