Transitions of Care Physician: SNF, Home & Hospital Lead

Central Health; Austin (TX); On-site; USD 230,000 - 320,000; Full time

Job summary

Central Health in Austin, TX seeks an Associate Medical Director of Post Acute and Care at Home Programs. As Transitions of Care staff physician, you will oversee patient care across SNFs, hospitals, and in-home visits, lead clinical teams, and ensure seamless transitions.

You will work with nurses, social workers, CHWs, physicians, and Dell Medical School to deliver high-quality care, mentor learners, and advance health equity in post-acute settings.

Qualifications

• MD or DO from an accredited medical school.
• Residency completed in Internal Medicine or Family Medicine.
• Board certification in Internal Medicine or Family Medicine required.
• Unrestricted Texas medical license upon hire.

Responsibilities

• Oversee patient care as Attending Physician across SNFs, hospitals, and home visits.
• Lead rounds with Advanced Practice Providers in SNFs.
• Coordinate transitions of care and navigation services with care teams.
• Collaborate with case managers, social workers, CHWs, and other clinicians.
• Provide direct patient care in post-acute settings and home visits.
• Develop and participate in electronic health record modules.
• Mentor Dell Medical School learners and supervise APPs.
• Ensure compliance with bylaws and support patient experience and outcomes.

Skills

Clinical leadership

Team supervision

Care coordination

Post-acute care navigation

Education

MD or DO degree

Residency in Internal Medicine or Family Medicine

Board certification in Internal Medicine or Family Medicine

TX medical license

Job description

Central Health in Austin, TX seeks an Associate Medical Director of Post Acute and Care at Home Programs. As Transitions of Care staff physician, you will oversee patient care across SNFs, hospitals, and in-home visits, lead clinical teams, and ensure seamless transitions.

You will work with nurses, social workers, CHWs, physicians, and Dell Medical School to deliver high-quality care, mentor learners, and advance health equity in post-acute settings.