Transitions of Care Physician Lead; MD

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 forlow-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 guidequality improvement, leads provider forums, and partners with Transitions of Care leadership, Central Healthteams, 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.

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 specializedtreatment when indicated.

Provide direct patient care and serve as an attending physician in Central Health's post-acute and transitional ca reprograms, 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, postacuteplacement, 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 usinginclusive, 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 implementstandardized, 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 evaluateoutcomes 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…