Transitions of Care Physician Lead (MD/DO)

Overview:

Under the Associate Medical Director of Post Acute and Care at Home Programs, the Transitions of Care Physician
Lead provides clinical and physician leadership across Central Health's Transition of Care programs, including
Skilled Nursing Facilities (SNFs), Transitional Care at Home (TCAH), acute hospital settings, and home-based care.
The physician leads and supports direct patient care, interdisciplinary clinical teams, and coordinated transitions for
low-income and uninsured patients.

The role serves as the physician champion for clinical operations, quality and safety, provider engagement,
program development, and strategic growth. The physician evaluates workflows and outcomes, uses data to guide
quality improvement, leads provider forums, and partners with Transitions of Care leadership, Central Health
teams, Dell Medical School, and community organizations to strengthen care transitions, patient experience, clinical outcomes, and system performance. This position models Central Health's vision, mission, and values and
advances patient-centered, equitable care.

Responsibilities:

Direct Clinical Care and Care Coordination:
Perform comprehensive assessments; order and interpret diagnostic studies; diagnose and treat diseases,
disorders, and injuries; prescribe appropriate medications and therapies; and refer patients for specialized
treatment when indicated.
Provide direct patient care and serve as an attending physician in Central Health's post-acute and transitional care
programs, including Skilled Nursing Facilities (SNFs), Transitional Care at Home (TCAH).
Lead clinical rounds with Advanced Practice Providers (APPs) and direct professional and ancillary health care staff
during patient care.
Collaborate with APPs, Nurses, CHWs, case management, primary care providers, hospital teams, and other
interdisciplinary partners to plan daily care and support safe transitions.
Attend care coordination meetings and help address complex care transition needs, barriers to discharge, postacute
placement, and longitudinal care coordination.
Facilitate communication and discharge planning for high-risk or readmitted patients to reduce avoidable utilization
and readmissions.
Educate patients and families regarding diagnoses, treatment plans, medications, and transitions of care using
inclusive, culturally humble, patient-centered practices.
Comply with facility and medical staff bylaws, Central Health policies, and applicable regulatory and accreditation
standards.
Clinical Operations and Workflow Optimization:
Evaluate clinical operations, staffing models, workflows, and care delivery processes across TOC Clinical programs
to improve safety, reliability, efficiency, access, and patient outcomes.
Partner with operational and clinical leaders to identify and resolve day-to-day workflow needs and implement
standardized, efficient processes.
Quality, Safety, and Data-Informed Improvement:
Lead quality improvement initiatives in collaboration with TOC staff focused on Transition of Care programs,
including patient safety, readmission reduction, utilization, care coordination, and patient experience.
Analyze and interpret SNF clinical, operational, quality, safety, utilization, and patient outcome data to identify
trends, validate performance, and prioritize improvement opportunities.
Support the development and use of dashboards, performance measures, and reporting structures to evaluate
outcomes and inform corrective actions and program decisions.
Physician Leadership and Provider Engagement:
Lead provider meetings and create forums for communication, performance review, clinical alignment, problem
solving, and sharing of best practices.
Provide clinical oversight, mentorship, education and feedback to APPs and other providers participating in
transitions of care programs, including SNF rounding.
Facilitate consensus among multidisciplinary and cross-functional teams and promote accountability for agreedupon
actions.
Program Development, Growth, and Strategy:
Work with Transitions of Care leadership to inform programmatic development, service design, implementation,
evaluation, and continuous improvement that support safe, reliable, efficient, and patient-centered care delivery.
Evaluate program growth opportunities, capacity needs, service expansion, and innovative care models that
advance Central Health's strategic objectives.
Align clinical resources, contracted services, and program initiatives with organizational goals related to health
outcomes, patient experience, equity, and total cost of care.
Community and Academic Partnerships:
Serve as a physician liaison with community partners, including SNF leadership, hospital partners, contracted
providers, regulatory bodies, and other organizations involved in transitions of care.
Build collaborative relationships with internal and external stakeholders to address operational issues, clarify
expectations, and improve continuity across care settings.
Be eligible for appointment to the faculty at Dell Medical School at The University of Texas at Austin in the
Department of Internal Medicine or Department of Population Health.
Engage, teach, and supervise Dell Medical School and other learners and participate in related educational
activities.
Organizational Responsibilities:
Communicate professionally and effectively with patients, families, colleagues, leaders, and community partners
while contributing positively to the team environment.
Demonstrate compassion and empathy and advance Central Health's health equity, diversity, inclusion, and
cultural humility commitments.
Prioritize responsibilities, manage multiple initiatives, maintain confidentiality, and perform other assigned duties.

Qualifications:

QUALIFICATIONS

M.D or D.O degree from an accredited medical school Required and Completion of a Residency in Internal Medicine or Family Medicine Required and Board certification in Internal Medicine or Family Medicine Required

Experience in a primary care setting/ambulatory clinic, acute care setting, or post-acute setting, with focus in patient navigation and complex transitions of care Preferred and Experience working with underserved populations Preferred