Family Practice - Geriatrics Physician

Primary Care Physician PACE Program

We are seeking a mission-driven Primary Care Physician to provide compassionate, comprehensive, and holistic care for older adults enrolled in a PACE program. This role centers on maintaining participant dignity and independence while delivering high-quality, individualized medical care in collaboration with an Interdisciplinary Team (IDT).

You will serve as the primary medical provider for a designated group of participants primarily at one Day Center with responsibilities that may extend to participant homes, hospitals, or skilled nursing facilities as needed. This position plays a critical role in decision-making and care planning that balances medical needs with realistic quality-of-life considerations.

Job Description

• Perform comprehensive initial evaluations including history and physicals, goals of care, and end-of-life discussions.
• Conduct bi-annual and as-needed reassessments, ensuring care aligns with participants' evolving health statuses.
• Diagnose and manage acute and chronic conditions in alignment with participants' goals and advance directives.
• Provide medical oversight of inpatient and specialty care, including hospital admissions and skilled nursing facility stays.
• Maintain timely, complete documentation in the medical record in accordance with PACE standards.
• Partner with Certified Registered Nurse Practitioners (CRNPs), nurses, social workers, therapists, and other IDT members to design and deliver coordinated care plans.
• Participate in daily IDT meetings to evaluate participant needs and develop or revise care plans.
• Lead or contribute to family conferences, care planning discussions, and team-based quality improvement initiatives.
• Actively participate in interdisciplinary discussions about cost-effective, value-based care decisions balancing clinical benefits with holistic participant outcomes.
• Be available for rotating 24/7 call coverage, shared among the physician team.
• Coordinate care transitions across settings (hospital, home, nursing facility) and facilitate timely discharge planning.
• Communicate effectively and consistently with participant families regarding medical decisions and care recommendations.