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About the Role

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. This role serves as the physician champion for clinical operations, quality and safety, provider engagement, program development, and strategic growth, advancing patient-centered, equitable care.

Responsibilities

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, post-acute 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.
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.
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.
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 agreed-upon actions.
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.
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.
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.

Requirements

M.D or D.O degree from an accredited medical school
Completion of a Residency in Internal Medicine or Family Medicine
Board certification in Internal Medicine or Family Medicine
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)
Experience working with underserved populations (Preferred)

Education Level

M.D or D.O degree
Residency in Internal Medicine or Family Medicine
Board certification in Internal Medicine or Family Medicine

About the Company

Central Health is dedicated to serving low-income and uninsured patients.