Physician - PACE

PACE Physician

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

ROLE OVERVIEW and PURPOSE

The PACE Physician provides comprehensive, person-centered medical care to older adults enrolled in the Program of All-Inclusive Care for the Elderly (PACE). The role centers on high-quality clinical care, including assessment, diagnosis, treatment, preventive care, chronic disease management, medication management, and coordination of care for participants with complex medical, functional, cognitive, and psychosocial needs.

As an active member of the interdisciplinary team (IDT), the PACE Physician contributes medical expertise to collaborative care planning and participant-centered decision making. The physician partners with nursing, rehabilitation services, behavioral health, social work, dietary services, home care, pharmacy, transportation, and other team members to support safety, function, independence, and quality of life.

The PACE Physician helps participants receive the right care in the right setting whenever possible. Care is primarily delivered through the PACE center and may also involve collaboration around care needs in the participant's home, community, facility, hospital, or other care setting when clinically appropriate and aligned with the participant's plan of care. Schedule: Monday-Friday 8am-5pm.

Responsibilities

• Provides comprehensive primary and geriatric medical care for PACE participants.
• Performs histories, physical examinations, medical assessments, and ongoing clinical evaluations.
• Diagnoses and manages acute and chronic medical conditions, including complex multimorbidity common in frail older adults.
• Develops individualized treatment plans that reflect the participant's medical needs, goals, functional status, and overall plan of care.
• Prescribes medications, treatments, health regimens, and therapeutic interventions consistent with evidence-based practice and participant goals.
• Reviews medications and supports appropriate medication optimization, including deprescribing when clinically appropriate.
• Orders and interprets laboratory studies, imaging, diagnostic tests, and specialty recommendations.
• Provides preventive care and health maintenance when clinically appropriate and consistent with participant goals.
• Responds to urgent medical concerns and supports timely intervention to reduce avoidable escalation of care.

• Manages participants with frailty, cognitive impairment, functional decline, behavioral health needs, polypharmacy, advanced illness, and multiple chronic conditions.
• Considers functional status, mobility, fall risk, cognition, nutrition, caregiver support, and social drivers of health in clinical decision making.
• Assesses medical decision-making capacity when clinically indicated.
• Incorporates palliative care principles into routine care for participants with serious illness or progressive decline.
• Participates in goals-of-care conversations, advance care planning, and POLST discussions when appropriate.
• Supports participants, caregivers, and families through complex medical decisions with clear, compassionate communication.

• Serves as an active member of the PACE IDT and contributes medical guidance to collaborative care planning.
• Participates in scheduled IDT meetings and care planning discussions.
• Partners with IDT members to develop, review, and revise individualized care plans.
• Supports team-based decision making while bringing clinical perspective to participant risk, medical stability, and treatment options.
• Collaborates with nursing, rehabilitation, social work, behavioral health, dietary, home care, pharmacy, and other disciplines to coordinate care.

• Partners with nursing staff, care coordinators, hospitals, skilled nursing facilities, specialists, community providers, and caregivers to support continuity of care.
• Provides clinical input during transitions between care settings, including emergency department visits, hospitalizations, skilled nursing facility stays, and return to the community.
• Reviews relevant hospital, facility, specialist, and diagnostic information to support safe and coordinated care.
• Supports communication with participants, caregivers, and external providers to reduce fragmentation and avoid gaps in care.
• Collaborates with the team to identify opportunities to prevent avoidable emergency department use, hospitalization, or institutionalization when safe and clinically appropriate.

• Supports care planning that considers the participant's home environment, community setting, functional needs, safety, preferences, and available supports.
• Collaborates with the interdisciplinary team to evaluate participant needs across care settings.
• Provides clinical guidance regarding participant care in community, residential, facility, and hospital settings as appropriate.
• May participate in home-based, facility-based, or community-based assessments when clinically appropriate and aligned with program needs.
• Promotes care that supports aging in place whenever safe, appropriate, and consistent with participant goals.

• Uses clinical judgment to support appropriate use of specialty care, diagnostic testing, medications, services, and other healthcare resources.
• Utilizes internal resources, e-consult services, and interdisciplinary expertise when clinically appropriate.
• Balances participant needs, safety, outcomes, and responsible resource use within the PACE model of care.
• Participates in utilization review, quality improvement, and care management activities as assigned.
• Supports thoughtful, evidence-informed care that avoids unnecessary fragmentation while ensuring timely access to needed services.

• Explains diagnoses, treatment options, medications, care plans, and expected clinical course in a clear and respectful manner.
• Engages participants, caregivers, and families in shared decision making as appropriate.
• Provides culturally sensitive, trauma-informed, and participant-centered communication.
• Supports informed consent and helps participants understand risks, benefits, and alternatives to proposed treatments.

• Maintains accurate, complete, and timely documentation in the medical record.
• Participates in quality improvement, performance improvement, and participant safety initiatives.
• Supports audit, survey, and regulatory readiness activities as assigned.
• Complies with applicable CMS, DHCS, PACE, organizational, safety, privacy, and HIPAA requirements.
• Reports unsafe, unethical, fraudulent, or unlawful behavior or activity according to organizational policy.

• Provides clinical oversight and supervision of advanced practice providers as assigned and within scope of organizational policy.
• Participates in teaching, mentoring, and clinical support of residents, students, rotational learners, and other trainees as appropriate.
• Promotes a collaborative learning environment and supports professional development within the care team.

• Participates in on-call responsibilities as assigned.
• Attends required meetings, trainings, and continuing education activities.
• Performs other duties related to participant care, program operations, and clinical quality as assigned.

Qualifications

Education/Experience

• Medical degree (MD or DO) from an accredited institution required.
• Valid CA Medical License required
• Board certification in a medical specialty required
• Current CA DEA licensure is required and is to be maintained as a condition of employment
• Current Basic Life Support (BLS) certification through an American Heart Association (AHA)-approved source is required upon hire and must be maintained as a condition of employment.
  • AHA-approved courses include an in-person, hands-on skills check with a certified instructor using