One Team One MissionPosition Summary:Under supervision of the Medical Director and in collaboration with PACE Physicians and Community-Based PACE Physicians 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 (GMWP) standards.
Essential Functions:- Provide primary care and acute illness evaluation and treatment for participants in collaboration with PACE Physicians and Community-Based PACE Physicians both in the center and in participant's homes.
- In collaboration with a physician, perform in-person comprehensive assessments (initial, semi-annual and unscheduled) on participants and coordinate with the IDT to develop a comprehensive care plan for each participant.
- Collaborate with physician(s) and IDT in discharge planning from acute or long-term care settings.
- In consultation with the PACE Physician and/or Community-Based PACE Physician, refer participants to medical specialists as indicated.
- In collaboration with the PACE Physician and/or Community-Based PACE Physician, manage care of participants in the nursing home, making regular visits as dictated by GMWP standards and participant needs.
- Be an active member of the IDT communicating participant changes, collaborating on care planning decisions and coordinating 24-hour care delivery.
- Work collaboratively with PACE Physicians, Community-Based PACE Physicians and other members of the IDT to ensure effective care coordination.
- Participate in rotating night and weekend calls
- At the direction of the Medical Director, review outcomes 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, PACE Physicians, Community-Based PACE Physicians and IDT to make policy and procedural improvements to reduce unnecessary utilization and improve participant health.
- Protect privacy and maintain confidentiality of all company procedures and information about employees, participants and families.
- Follow GMWP 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.
Education and Certification:- Graduate of an accredited Physician Assistant program.
- Physician Assistant State License.
- Valid DEA.
- Certification as a Physician Assistant (PA)/Provider with prescriptive authority.
- Current Basic Life Support (BLS) and CPR Certification.
- Current driver's license and proof of auto insurance.
Skills and Experience:- Minimum of 2 years working with the frail or elderly.
- Ability to build strong working relationships with other providers and care team.
- Creative and enthusiastic commitment to the "triple aim" - dedication to improving experience, health, and value for PACE participants.
- Current knowledge of chronic care/geriatric issues and best practices.
- Work well in a managed care environment with an interdisciplinary team (IDT).
- Ability to process information accurately and timely.
- Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and the IDT.
- Working knowledge of PACE regulations preferred.
Medical Clearance:Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
Job offers are contingent upon a successful pre-employment drug screen, background check, and physical assessment.
