What you will do: 

• Participate as a member of the interdisciplinary team (IDT) and in initial, semi-annual, unscheduled, and annual assessments; attend morning updates and report changes in participants baseline status to appropriate staff on a daily basis. 

• Provide initial and ongoing participant assessments, care plan development, and implementation of care plan. Integrate the primary care treatment plan into the overall plan of care developed by the interdisciplinary team. 

• Refer participants to medical specialist as indicated. Manages all care of participants in the nursing home: Provides regular visits to manage the care of participants in the nursing home in collaboration with the Interdisciplinary Team; maintains communication with nursing home staff for continuous monitoring of PACE participants on a case-by-case basis; admits nursing home participants to hospital when necessary. 

• Oversees and manages participants use of medical specialist and inpatient care. Communicates and follows up with specialist regarding outcome of visit. 

• Function as a member of the interdisciplinary team. Maintains regular attendance at, and participants in interdisciplinary team meetings; communicates participant changes, collaborates on care planning decisions and coordination for 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. 

• Complete documentation and uses appropriate diagnostic coding. 

• Advise the Medical Director in ways and means to establish better accountability of PO services to participants and referral sources, keeps Medical Director aware of needed material and human resources as program expands.
• Assist 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.