Bilingual Transition of Care Nurse

Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity.

The primary location for this role remote, the expected schedule requirement is 3x12s (Monday-Wednesday or Wednesday-Friday). What You'll Do: As a Nurse Care Manager on our Transition of Care team (TOC Nurse) at Imagine Pediatrics you will develop positive, long-term relationships with pediatric offices, specialty practices, hospital discharge planners/social workers, private duty nurses and aides, and other members of the community teams to support eligible patients and their families. The TOC Nurse will directly outreach Imagine Pediatric patients after they are discharged from the hospital to assist with coordination of care. You will collaborate with other members of the interdisciplinary team including MDs, APPs, social workers, community health navigators, and clinical pharmacy to ensure comprehensive care and support for families.

Outreach caregivers and patients after hospital or Emergency Department discharge for a Transition of Care visit Leverage reporting and dashboards to prioritize telephonic outreach to patients and caregivers Review discharge plan with the caregiver and assess for any barriers the family may have post discharge Provide anticipatory guidance and education to families Triage new or worsening symptoms and escalate to a provider as necessary Leverage reporting and dashboards to prioritize telephonic outreach to patients and caregivers Assess the need for community resources and collaborate with Community Health Navigators and other team members to ensure families have all necessary support post-discharge Coordinate care between patients and their PCP/specialists post discharge to ensure continuity of care Re-engage families and provide education about Imagine Pediatric services Perform Other duties as assigned