- Perform comprehensive assessments for participants and coordinate with the IDT to develop a comprehensive care plan for each participant
- Be an engaged member of the IDT, communicating participant changes, collaborating on care planning arrangements, and coordinating 24-hour care delivery
- Work collaboratively with network providers and other members of the IDT to ensure effective care coordination, particularly around hospital discharge, short-term, and long-term placement
- Provide direction and guidance to Nurse Practitioners
- Oversee participants' use of medical specialists and inpatient care
- Participate in rotating night and weekend call
- Oversee all care of participants in the nursing home, providing regular visits as dictated by PACE standards and participants' needs
- Review outcome and utilization data, including adverse events, hospitalizations, and use of specialists, in collaboration with the IDT to identify opportunities for improved care and operations
- Successful completion of a residency program accredited by the Accreditation Council for Graduate Medical Education
- Master's degree/doctorate degree
- Board Certification - Internal Medicine or Family Practice
- Board Certification - Geriatrics preferred
- Active California Physician License without restrictions
- State CDS Certification and DEA Registration
- Valid state driver's license with a clean DMV record
- Copy of recent vehicle insurance required
- Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and the IDT
- Current knowledge of chronic care/geriatric issues and best practices
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