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 4x10s (Tuesday-Friday).

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 discharge for a Transition of Care visit Review discharge plan with the caregiver and assess for any barriers the family may have post discharge Leverage reporting and dashboards to prioritize telephonic outreach to patients and caregivers Collaborate with Transition of Care Coordinator and other team members to ensure families have everything they need post discharge Coordinate care between patients and their PCP/specialists post discharge to ensure continuity of care Perform Other duties as assigned