Eldercare PACE Primary Care Physician

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Department: Job Description Summary:

The PACE Primary Care Physician provides comprehensive, participant-centered primary and geriatric care to frail older adults enrolled in the Program of All-Inclusive Care for the Elderly. Participants generally meet a nursing-home level of care but continue to live independently in the community.

The physician will provide primary care for an assigned panel of PACE participants and physician-level clinical guidance for the broader PACE population.

Working with the PACE Medical Director, nurse practitioners, nursing staff, and interdisciplinary team, the physician ensures coordinated, evidence-based, and cost-effective care across the PACE center, participants’ homes, hospitals, skilled nursing facilities, assisted living facilities, and other care settings.

Essential Clinical Duties

Serve as the primary care physician for an assigned panel of PACE participants, with panel assignments determined based on program enrollment, participant complexity, provider capacity, and operational needs.

Provide comprehensive longitudinal care to medically complex, frail older adults, including diagnosis, treatment, preventive care, chronic-condition management, acute care, and health maintenance.

Conduct comprehensive initial, periodic, annual, semiannual, and unscheduled medical assessments and reassessments in accordance with PACE requirements, organizational policies, and accepted standards of practice.

Obtain and document complete medical histories and physical examinations, including review of prior hospitalizations, specialist records, diagnostic studies, laboratory findings, medication history, functional status, and relevant psychosocial information.

Evaluate acute and emergent changes in participant condition and determine the most appropriate level and setting of care.

Order, review, and interpret laboratory tests, imaging studies, and other diagnostic procedures.

Prescribe and manage medications, therapies, treatments, medical equipment, and other medically necessary services.

Monitor for polypharmacy, medication interactions, potentially inappropriate medications, treatment duplication, and medication-adherence concerns.

Provide preventive care, including recommended screenings, immunizations, risk assessments, and monitoring of relevant clinical indicators.

Refer participants to specialists when medically indicated and integrate specialist recommendations into the participant’s overall treatment plan.

Provide participant care at the PACE center and, when clinically necessary, in participants’ homes, hospitals, skilled nursing facilities, assisted living facilities, rehabilitation facilities, and other care settings.

Participate in participant and family meetings involving significant changes in condition, treatment decisions, goals of care, placement needs, or end-of-life planning.

PACE Program-Specific Responsibilities

Interdisciplinary Care Planning: Participate as a core member of the PACE interdisciplinary team, contributing medical expertise to participant assessments, individualized plans of care, case reviews, service decisions, and ongoing coordination of care.

Clinical Oversight and Provider Collaboration: Provide physician-level clinical guidance for the broader participant population and serve as a clinical resource to PACE nurse practitioners and other clinical staff. Promote consistent clinical standards, escalation pathways, documentation practices, and evidence-based care while working under the overall medical oversight of the PACE Medical Director.

Transitions and Complex Care Management: Coordinate care across hospitals, emergency departments, skilled nursing facilities, rehabilitation facilities, assisted living facilities, participants’ homes, and other settings. Support timely discharge planning, medication reconciliation, post-discharge follow-up, and safe transitions of care.

Utilization and Medicare Risk Management: Support appropriate utilization of hospital, emergency, specialty, pharmacy, diagnostic, home health, and nursing-facility services. Participate in the review of high-risk, high-cost, and high-utilization cases and promote accurate clinical documentation of participant diagnoses and medical complexity.

Quality, Compliance, and Participant Safety: Practice in accordance with CMS PACE requirements, Florida law, medical staff requirements, organizational policies, and professional standards. Participate in quality improvement, patient safety, risk management, regulatory readiness, clinical audits, and corrective-action activities.

On-Call and Clinical Coverage: Participate in the PACE provider on-call rotation and help ensure access to physician-level medical decision-making and continuity of care during evenings, weekends, holidays, emergencies, and provider absences.

Participant and Family Communication: Provide clear, culturally responsive education to participants and caregivers regarding diagnoses, medications, treatment options, disease progression, advance directives, goals of care, and available services.

Program and Community Collaboration: Maintain effective working relationships with participants, families, hospitals, specialists, nursing facilities, pharmacies, community providers, and contracted services. Represent the PACE program professionally in clinical and community settings.

Additional Responsibilities

Maintain required licensure, credentials, privileges, certifications, competencies, and continuing education. Participate in emergency preparedness activities and perform other duties as assigned in support of participant care, regulatory compliance, and PACE operations.

Minimum Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited medical school.
• Completion of an accredited residency in Internal Medicine, Family Medicine, or another primary care specialty appropriate to the PACE population.
• Current unrestricted Florida medical license, or eligibility to obtain licensure before employment.
• Board certified or board eligible in Internal Medicine or Family Medicine.
• Current DEA registration.
• Current Basic Life Support certification; Advanced Cardiovascular Life Support certification preferred.
• Ability to obtain and maintain applicable medical staff membership and clinical privileges.

Minimum of 2 years of clinical experience caring for frail older adults, medically complex seniors, or individuals requiring a nursing-home level of care.

Demonstrated knowledge of geriatric medicine and elder care, including multimorbidity, cognitive and functional impairment, polypharmacy, fall risk, care transitions, advance-care planning, and goals-of-care discussions.

• Ability to assess and manage acute and chronic conditions commonly affecting the geriatric population.
• Ability to work effectively with nurse practitioners and within an interdisciplinary care model.
• Three years of post-residency clinical experience preferred.
• Bilingual English and Spanish proficiency.

Preferred Qualifications

• Fellowship training or board certification in Geriatric Medicine.
• Skilled nursing facility or nursing-home experience.
• Hospitalist experience.
• Emergency department or urgent care experience.
• Medicare Advantage, Medicare risk, accountable care, population health, or capitated-care experience.
• PACE, home-based primary care, or complex care-management experience.
• Palliative care and serious-illness management experience.
• Utilization management, clinical documentation, risk-adjustment, or transitions-of-care experience.

Key Skills and Abilities

• Strong primary care and geriatric clinical knowledge.
• Ability to manage medically complex, frail, cognitively impaired, and functionally impaired older adults.
• Sound clinical judgment in acute, complex, and uncertain situations.
• Strong interdisciplinary collaboration and communication skills.
• Understanding of care transitions, population health, and responsible healthcare utilization.
• Timely, accurate, and defensible clinical documentation.
• Ability to provide clinical guidance to advanced practice providers and other clinical staff.
• Ability to travel within the PACE service area and provide care in multiple settings.
• Ability to communicate effectively and compassionately with participants, families, caregivers, and clinical partners.

Key Performance Expectations

• Quality, safety, and continuity of participant care.
• Effective management of the assigned participant panel.
• Timely assessments, documentation, orders, and clinical follow-up.
• Meaningful participation in IDT meetings and care planning.
• Responsiveness to acute participant and provider needs.
• Effective collaborat