PACE Physician, Full-Time

Program Information

PACE Georgia is dedicated to empowering aging adults to live with dignity, independence, and quality of life by delivering compassionate, comprehensive, and coordinated care.

PACE stands for the Program of All-Inclusive Care for the Elderly — a model of care that supports older adults who wish to remain in their homes and communities rather than move to a nursing facility.

Through PACE Georgia, we partner with participants and their families to provide personalized healthcare, social support, and community-based services that honor the unique needs and values of every individual we serve.

Mission Statement:

To support Georgia’s rapidly growing aging population with comprehensive, coordinated care enabling them to live independently and with dignity.

Vision Statement:

To transform the landscape of elder care in Georgia by setting the standard for excellence in integrated, community-based services that promote longevity and quality of life for aging in place.

Job Summary

The PACE Primary Care Physician provides direct primary medical care to PACE program participants and clinical supervision to PACE Clinic personnel, including mid-level practitioners.

The PACE Primary Care Physician is a PACE Interdisciplinary Team (IDT) member and is responsible for completing comprehensive initial primary care assessments for new PACE participants and primary care reassessments on existing PACE participants as part of the PACE IDT care planning process.

The PACE Primary Care Physician manages participants’ chronic illnesses and medical conditions, initiates primary care interventions per industry best practices, and evaluates and treats PACE participants during acute illness episodes.

The PACE Primary Care Physician provides primary care education to participants, caregivers, and PACE staff.

Position Responsibilities

• Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing a comprehensive initial primary care assessment for new PACE participants and primary care reassessments on existing PACE participants as part of the PACE IDT care planning process.
• In collaboration with the IDT, develops care plans for primary care and delivers primary care to participants, identifying and considering the medical, physical, social, and emotional needs of PACE participants.
• Manages participants’ chronic illnesses and medical conditions, initiates primary care interventions per industry best practices, and evaluates and treats PACE participants during acute illness episodes.
• Responsible for participant medication management.
• In collaboration with the IDT, coordinates the medical care of PACE participants across the care continuum to include the community, hospitals, and long-term care settings.
• Refers participants to contracted medical providers as indicated; communicates with and follows up with contracted medical providers regarding participant medical care and the outcome of outside medical provider encounters.
• Provides discharge support and guidance during care transitions from the hospital back to the community.
• Monitors PACE participants for changes in their health and psychosocial status requiring a primary care reassessment. Promptly communicates pertinent changes in participant status to the IDT.
• Completes and maintains primary care physician documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy.
• Provides primary care education to participants, caregivers, and PACE staff.
• Attends IDT and morning meetings and reports on participant’s medical status
• Assist Hospice House Team, when needed.
• Participates in the primary care provider on-call rotation as required.
• Participates as a member of the Fraud, Waste, and Abuse Committee.
• Supports the PACE QI program and participants in PACE QI activities as assigned.

CMS Regulation Requirements and Other Preferred Requirements

• Required.MD. or DO with current license to practice medicine in the State of Georgia.
• Preferred- Board-certified in internal medicine or family practice with advanced certification in geriatrics.
• Required- One year of direct primary care experience with a frail, elderly, or long-term care population. Experience caring for frail older adults' physical, mental, emotional, and social needs. Demonstrates the ability to work in an interdisciplinary team setting effectively.
• Demonstrates skills and knowledge as outlined in primary care provider competency requirements, including effective skills in physical assessment and chronic disease management for frail older adults.
• Required- Current DEA registration.
• Preferred- Staff privileges at PACE Georgia contracted hospitals and skilled nursing facilities.
• Preferred Experience working in a managed care environment, demonstrating the ability to successfully lead primary care provider staff and work effectively with hospitals, nursing homes, ancillary services providers, and physician specialists to coordinate and manage care for a medically complex population.
• Experience leading quality improvement and physician leadership initiatives.
• Have not been convicted of criminal offenses related to involvement in Medicaid, Medicare, other health insurance or health care programs.
• Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.
• Not excluded from participating in Medicare and Medicaid programs.