Primary Care Provider MD

3 months ago
Job ID
# of Openings
PACE Pathways


Provides primary care and continuous medical coverage, directly provides services to Immanuel Pathways program participants. Practices collaboratively with the Medical Director and Nurse Practitioner(s) following protocols developed within the specified Code of State Regulations. Provides participants and their caregivers with instruction and education. Functions as a member of the Interdisciplinary Team (IDT) and informs the IDT of the medical condition of each participant, remaining alert to pertinent input from other team members, participant’s caregivers, as well as documenting changes in a participant’s medical record consistent with documentation policies. Works with Clinic Manager to coordinate scheduling and care for participants in the clinic. Performs rounds in the Immanuel Pathways contracted provider locations (i.e.: nursing home, hospital and assisted living. Supports and lives out Immanuel’s Mission and CHRIST Promises.


Key Areas

Key Responsibilities and Duties of the Job

80% Participant Care

  • Performs initial in-person comprehensive history and physical on new Immanuel Pathways participants.
  • Conducts an in-person reassessment semi-annually and as needed.
  • Coordinates with the Interdisciplinary Team to develop a comprehensive plan of care for each participant. Integrates the primary care treatment plan into the overall plan of care developed by the IDT. Interacts with team members to meet emergent and acute need of participants.         Participates in discharge planning for acute and long-term placement.
  • Evaluates and treats participants during acute illness.
  • Refers participants to medical specialist as indicated, communicates and follows up with specialist regarding outcome of visit. Oversees and manages participant’s use of medical specialist and inpatient care.
  • Admits participants to the hospital or coordinates with hospital services; providing primary care responsibilities for medical management and provides updates to IDT. In conjunction with the hospital and IDT, plans and coordinates discharge.
  • Manages care of participants in the nursing home: Provides regular visits as dictated by nursing home standards and participant needs. Performs telephone contact with nursing home staff as required; coordinates admits for nursing home participant to hospital when necessary.
  • Participates in rotating night and weekend call.
  • Functions as a member of the Interdisciplinary Team. Maintains regular attendance at, and participants in Interdisciplinary Team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery.
  • At the direction of the Medical Director, reviews medical outcomes/statistical and utilization data, including reviewing of necessity of hospitalizations, and use of specialists. When problems are identified he/she works with the Medical Director to establish best practices and works with clinical staff and Interdisciplinary Team to make appropriate procedural and or operational changes to avoid unnecessary hospitalizations and improve the health of participants.
  • Completes and documents appropriate diagnostic coding.

·         Advises the Medical Director in ways and means to establish better accountability of Immanuel Pathways services to participants and referral sources, keeps Medical Director aware of needed material and human resources as program expands.

  • Supports the Medical Director to develop protocols that will be approved annually, collaboratively working with the Nurse Practitioner.         Supports the consultation as a supervising physician who will be available at all times, either on site or by telephone.

10% Compliance

  • Assists with the development of policies and procedure, standards of care; performs on-going monitoring and evaluation of patient care practice and service delivery; provides guidance and training to staff regarding medical and quality assurance issues.
  • Participates in and supports Quality Improvement Initiatives.
  • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
  • Follows all Immanuel Pathways Policies and Procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
  • Complies with state Home Health Licensure regulations for home care.

5% Professional Activities

  • Participates in continuing education classes and any required staff and training meetings. Maintains professional licensure and certifications.
  • Provides information about Immanuel Pathways Program to interested individuals and groups in adherence to PACE regulations.

5% Other

·         Performs other duties as required or requested.

·         Participate in the recruitment, initial, and ongoing training of Nurse Practitioners and may participate in their periodic performance evaluations.



  • Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree is required.
  • Board certified in Internal Medicine, Family Medicine, or Geriatric Medicine desired.
  • Current state license and DEA registration required.
  • Meets requirements for 42 CRF Part 410.20.


  • One (1) year of experience working with a frail or elderly population.
  • Three (3) years of practicing medicine in a clinical or hospital setting is required.  

Other Requirements-

  • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
  • Must have a valid driver’s license, proof of insurance and have means of transportation.
  • Basic Life Support (BLS) Skills i.e. Health Care Level Cardiopulmonary resuscitation (CPR); Automated External Defibrillator (AED); First Aide (FA).

KSA- Knowledge Skills and Abilities-

  • Knowledge of current concepts, theories and practices related to home and community-based care for the elderly and disabled adults.
  • Knowledge of health care delivery and financing systems, including Medicaid, Medicare, waiver programs, prospective and systems with a monetary cap, public health programs and Health Maintenance Organization (HMO)/Managed Care.
  • Knowledge of the PACE regulations
  • Knowledge of physical, mental and social needs of frail older adults.
  • Skilled in oral and written communication
  • Skilled in organizing time, priorities, and duties
  • Ability to lead and work within the interdisciplinary setting.
  • Ability to supervise medical staff effectively.
  • Ability to manage changing priorities per needs of the PACE program and the agency.
  • Ability to chart via Electronic Health Records
  • Proven experience and basic computer proficiency (internet, email, Microsoft Office)


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