PACE Physician Transitions of Care Clinical Champion

2 months ago

San Marcos, United States Gary and Mary West PACE Full time

$10,000.00 sign On Bonus


Gary and Mary West PACE is a growing and thriving all inclusive day center for the fragile elderly. We are located in San Marcos, CA.

We are a Non-Profit Agency.


We offer several benefit plans to chose from and also have a great 403B program plus tuition re-imbursement program.

Come work for a company with a wonderful work life balance.



Why Work for Gary and Mary West PACE?

Because you desire work/life balance and have a passion to make a difference in the lives of North County seniors and their families

You will receive generous pay and a benefits program focused on your health and wellness that includes 10 paid holidays, 3 weeks of PTO, a 5% employer-match to our 403b retirement program.

Because we encourage professional development and support all staff to expand their skillset, providing an annual education allowance.

You will be part of a distinct company culture where work feels like family and collaborate with a multi-disciplinary team environment where you are appreciated and valued.

Come do your best work where your contribution matters

About PACE:

Philanthropists Gary and Mary West founded West Health with the mission of enabling seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life, and independence. The Gary and Mary West PACE (Program of All-inclusive Care for the Elderly), affiliated with West Health (), is a new non-profit that delivers medical, social, and behavioral services to the frail elderly to the North County of San Diego. This PACE center will be entrepreneurial in nature and will focus on innovations and bringing new processes to the traditional PACE environment.

We're looking for passionate healthcare providers who want to be part of a team dedicated to enable seniors to live in their communities as independently as possible by providing compassionate, comprehensive health and supportive care.

One Team One Mission

Under supervision of the Medical Director, the PACE Physician provides assessment, planning, primary care, and continuous medical coverage to PACE participants in an interdisciplinary team environment and in accordance with Gary and Mary West PACE standards.

Essential Functions

  • Provide complex primary care and acute illness evaluation and treatment for participants on an as needed basis via in person, at home or telehealth visits.
  • Perform in-person comprehensive assessments on participants and coordinate with the IDT to develop a comprehensive care plan for assigned participant panel of up to 110 participants.
  • Be an active member of the IDT communicating participant changes, collaborating on care planning decisions and patient centered care in line with West PACE mission.
  • Work collaboratively with case management RNs and other members of IDT to provide clinical input and care coordination in Transitions of Care scenarios and participate in facility and family care conferences as needed.
  • Conduct post hospital and post ED discharge visits within 1 week of discharge as well as acute visits focused on ED and hospital utilization reduction for high risk patients.
  • Provide clinical guidance and support to Nurse Practitioners. NPs currently report to medical director but supervisory role for PACE physician may be considered if the right fit.
  • Along with the Medical director, serve as a liaison outpatient and inpatient specialist to communicate and improve care for PACE participants.
  • Participate in every 5-6 week rotating telephonic only night and weekend.
  • Provide home or SNF visits as needed based on clinical criteria and/or by Gary and Mary West PACE's standards and participants' needs.
  • At the direction of the Medical Director, review outcomes, coding and utilization data, including review of necessity of hospitalizations and use of specialists; establish best practices with the Medical Director, and collaborate with clinical staff, Community-Based PACE Physicians, and IDT to make policy and procedural improvements to reduce unnecessary utilization and improve participant health.
  • Protect privacy and maintain confidentiality of all company procedures and information about employees, participants and families.
  • Follow Gary and Mary West PACE policies and procedures and participate in any required QI activities, staff training and meetings.
  • Maintain professional licensure and certifications.
  • Act only within the scope of practice.

Education and Certification


  • Successful completion of a residency program accredited by the Accreditation Council for Graduate Medical Education.
  • MD or DO degree.
  • Board Certification - Internal Medicine or Family Practice.
  • Additional certifications in Geriatrics, Hospice and Palliative Care, Addiction Medicine or Pain is desirable but not required.
  • Active CA physician license without restrictions.
  • Current Basic Life Support (BLS) training.
  • State CDS Certification and DEA Registration.
  • Current driver's license and proof of auto insurance.

Skills & Experience

  • Current knowledge of chronic care/geriatric issues and best practices.
  • Current medical knowledge of behavioral health and substance use management.
  • Interest or experience in post acute care or transitions of care role.
  • Work well in a managed care environment with an interdisciplinary team (IDT).
  • Ability to build strong and collegial working relationships with other providers and care team.
  • Creative and enthusiastic commitment to the "triple aim" - dedication to improving experience, health, and value for PACE participants.
  • Interest or experience in community based healthcare interventions aimed at keeping high risk seniors in the home setting while providing patient centered care.
  • Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and the IDT.
  • Working knowledge of PACE regulations would be a bonus.

Medical Clearance:

Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.

Job offers are contingent upon a successful pre-employment drug screen, background check, Physical and health screen. Proof of COVID-19 vaccination required. Must have a valid Driver License and proof of auto insurance.

Gary and Mary West PACE provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, pregnancy, military and veteran status, age, physical and mental disability, genetic characteristics, gender, gender identity, gender expression or sexual orientation or any other considerations made unlawful by applicable state or local laws.


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