Geriatrics PA: PACE & Community-Based Elder Care

Rochester Regional Health; City of Rochester (NY); On-site; USD 100,000 - 150,000; Full time

Job summary

Rochester Regional Health is seeking a Physician Assistant for ElderONE, its comprehensive PACE program, to deliver integrated, person-centered care to older adults in home and community settings. You will collaborate within a highly engaged interdisciplinary team to maintain participant independence and quality of life.

The role emphasizes care coordination, chronic condition management, and participation in pre-enrollment and discharge planning activities.

Qualifications

• Passion for serving older adults and supporting nursing home eligible individuals to remain safely in the community.
• Experience working with older adults and/or medically complex patient populations preferred.
• Experience in PACE, Primary Care, Long-Term Care, Home Care, Geriatrics, or community-based care settings preferred.
• Knowledge of care coordination, value-based care, and interdisciplinary team-based care preferred.
• Strong problem-solving, organizational, and relationship-building skills.
• EPIC experience preferred; PACE experience a plus.

Responsibilities

• Clinical Care. Evaluate and manage acute, sub-acute, and chronic clinical needs of older adults. Collaborate with physicians and interdisciplinary team members to develop individualized treatment plans that align with participant goals, functional status, and quality of life.
• Care Management. Complete comprehensive clinical reviews of chronic conditions and document in the medical record. Assess and reassess participant-specific goals of care while reviewing specialty recommendations and coordinating appropriate follow-up care.
• Interdisciplinary Team Administrative Duties. Attend daily interdisciplinary team meetings and care planning conferences. Review laboratory results, specialty notes, and diagnostic testing, initiating orders when appropriate. Complete pre-enrollment visits and support care transitions and discharge planning activities.
• PACE & Community-Based Care. Support approximately 800+ ElderONE participants across multiple community-based sites and home settings. Partner closely with Primary Care, Home Care, Extended Care, and other system services to provide coordinated, person-centered care for a complex older adult population.
• Program Growth & Collaboration. Contribute to a growing and evolving PACE program through interdisciplinary collaboration, quality improvement efforts, process enhancements, and innovative approaches to care delivery.
• Infection Control. Utilize infection control equipment and safety guidelines to minimize and prevent exposure to communicable diseases, infectious body fluids, and risks associated with patient treatment.

Skills

Interdisciplinary teamwork

Geriatrics care

Care coordination

Clinical problem-solving

Education

BS: Physician Assistant (Required)

Tools

EPIC

Job description

Rochester Regional Health is seeking a Physician Assistant for ElderONE, its comprehensive PACE program, to deliver integrated, person-centered care to older adults in home and community settings. You will collaborate within a highly engaged interdisciplinary team to maintain participant independence and quality of life.

The role emphasizes care coordination, chronic condition management, and participation in pre-enrollment and discharge planning activities.