Coordinated care model which provides preventive, primary, acute and long-term care services designed to assist older individuals to live as independently as possible while continuing to live within their community.PACE serves individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment and live in a PACE service area. While all PACE participants must be certified to need nursing home care to enroll in PACE, only about 7 percent of PACE participants nationally reside in a nursing home. If a PACE enrollee needs nursing home care, the PACE program pays for it and continues to coordinatethe enrollee's care. We encourage fellowship and independence while serving seniors and their families with dignity and respect. Delivering all needed medical and supportive services, PACE is able to provide the entire continuum of care and services to seniors with chronic needs while maintaining their independence in their home for as long as possible.Job Description:Position serves as Outpatient PCP and skilled facilityOccasional home care work may be required.Full-time opportunity: Monday " Friday, 8:00 am " 4:30 pmOn average, there are seven on-call days (evenings/weekends) with weekend telephone triage.See between2-8 patients per dayProvide initial and ongoing participant assessments, care plan development, and implementation of care plan.Integrate the primary care treatment plan into the overall plan of care developed by the interdisciplinary team. Interacts with team members to meet emergent and acute need of participants. Evaluates and treats participants Primary Care Physician during acute illness.Manages all care of participants in the nursing home: Provides regular visits to manage the care of participants in the nursing home in collaboration with the Interdisciplinary Team; maintains communication with nursing home staff for continuous monitoring of PACE participants on a case-by-case basis; admits nursing home participants to hospital when necessary. Oversees and manages participants use of medical specialist and inpatient care. Communicates and follows up with specialist regarding outcome of visit.Function as a member of the interdisciplinary team. Maintains regular attendance at, and participants in interdisciplinary team meetings; communicates participant changes, collaborates on care planning decisions and coordination for 24-hour care delivery.At the direction of the Medical Director reviews medical outcomes/statistical and utilization data, including reviewing of necessity of hospitalizations, and use of specialists. When problems are identified he/she works with the Medical Director to establish best practices and works with clinical staff and interdisciplinary team to make appropriate procedural and or operational changes to avoid unnecessary hospitalizations and improve the health of participants.Complete document