Transitions of Care Physician (MD/DO)

Overview:

Under the Associate Medical Director of Post Acute and Care at Home Programs, the Transitions of Care staff
physician will oversee patient care, manage clinical teams, and provide direct care to low-income and uninsured
patients in post-acute settings such as Skilled Nursing Facilities, hospitals, and home visits.

This position's responsibilities encompass acting as an Attending Physician, leading rounds with Advanced
Practice Providers in a skilled nursing facility and providing medical care in the home of patients. The staff
physician will also collaborate with Nurse Case Managers, Social Workers, Community Health Workers,
Physicians, and other healthcare professionals to provide inpatient care in partnership with Dell Medical School
and coordinate transitions of care and navigation services. This position models a commitment to Central
Health's vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.

Responsibilities:

Perform comprehensive physical assessment of patients using observation, inspection, auscultation, palpation
and percussion.
Order or execute various tests, analyses, and diagnostic images to provide information on patient’s condition.
Diagnose and treat diseases, disorders and injuries based on patient’s medical history and results of physical
assessment and refer patients to medical specialist or other practitioner for specialized treatment.
Prescribe medications and therapies for treatment, preventive care, and contraception.
Instruct patients and their families regarding medical therapies, procedures performed, plan of care, and follow
up visits.
Direct professional and ancillary health care staff during treatment of patients.
Provide direct patient care in Skilled Nursing Facilities and acute hospital settings.
Be eligible for appointment to the faculty at Dell Medical School, The University of Texas at Austin, in the
Department of Internal Medicine or Department of Population Health.
Oversee and practice medicine specific to home-based care.
Participate in the development, building, and training of electronic health record modules.
Engage, lead, and supervise learners affiliated with Dell Medical School and participate in teaching endeavors
with Dell Medical School learners.
Essential Functions
Collaborate with APPs, Transitional Care at Home team and the case management team for the Transitional Care
at Home program with home visits.
Serve as an attending physician in SNFs.
Develop and deliver effective public presentations in partnership with leadership.
Comply with facility and medical staff bylaws for safe patient care in post-acute settings.
Coordinate with primary care providers and healthcare teams for MAP patient care in hospitals and post-acute
environments.
Communicate effectively with patients, families, colleagues, and healthcare professionals.
Prepare and provide necessary reports and forms as required.
Coordinate and collaborate with Central Health’s advanced-practice providers for hospital and skilled nursing
facility services.
Plan and coordinate daily care with Central Health’s care team members.
Foster collaborative relationships with affiliates, providers, officials, regulatory bodies, patients, and the
community.
Work closely with diverse patient populations.
Facilitate effective communication with Case Management/Care Coordination teams to prevent readmissions.
Collaborate proactively for discharge teaching of readmitted/high-risk patients.
Develop, implement, and evaluate service delivery, patient experience, and care management activities.
Exhibit compassion, vulnerability, and empathy when working with employees and patients and advancing
Central Health’s health equity and DEI goals.
Provide patient centered care that is inclusive and focuses on cultural humility.
Share a commitment to diversity and inclusion awareness and health equity practices across Central Health.
Prioritize duties, demonstrating strong organization and time management skills.
Interact professionally, contributing positively to the team environment.
Perform other assigned duties.
Supervisory Responsibilities:
Supervise Advanced Practice Providers in the SNF setting, including rounding.
Supervise quality, utilization, and care review conferences for post-acute program patients in collaboration with
APPs.
Manage and support the implementation of new initiatives and ensure strategy and initiatives are coordinated.
Assist in assessing learning needs, developing competency plans, and providing learning opportunities.
Proactively address employee needs and concerns.
Develop expertise within the department and seek employee input.
Facilitate consensus among diverse groups.
Evaluate staff performance and competency, providing direct feedback.
Adhere to all local, state, and federal regulations.

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

 

Unrestricted license to practice medicine in the State of Texas Upon Hire Required

 

Active board certification in Internal Medicine or Family Medicine, OR passage within 2 Years Required

Current Drug Enforcement Agency (DEA) registration for the purpose of writing
prescriptions Upon Hire Required

 

Basic Life Support (BLS) - obtained through approved American Heart Association or Red Cross