Pediatric Transition Care Manager
Affirmed Home Care•Rochelle Park, NJ
•Hybrid
About The Position
Affirmed Home Care is seeking an experienced Pediatric Transition Care Manager to coordinate care for children and adolescents transitioning between care settings—including hospital discharges, specialty pediatric practices, school-based services, and home or community care. The ideal candidate will bring a strong, established referral network across New Jersey hospitals, pediatric provider groups, and school systems, and will serve as the primary liaison ensuring continuity of care, family support, and successful patient outcomes throughout each transition.
Requirements
- Active New Jersey RN, LSW, LCSW, or related clinical license in good standing.
- Minimum 3 years of pediatric care management, case management, or transition-of-care experience in New Jersey.
- Established and active referral relationships with NJ hospitals, pediatric practices, and/or school systems.
- Working knowledge of NJ Medicaid, NJ FamilyCare, EPSDT, IEP/504 processes, and pediatric specialty care networks.
- Strong clinical assessment, documentation, and care planning skills.
- Excellent communication, organization, and relationship-building abilities.
- Valid NJ driver's license, reliable transportation, and willingness to travel within assigned territory.
- Proficiency with electronic health records and care management software.
Nice To Haves
- Bachelor's or Master's degree in Nursing, Social Work, Public Health, or related field.
- CCM (Certified Case Manager) or equivalent certification.
- Bilingual English/Spanish.
- Prior experience with medically complex children, behavioral health, or special education populations.
Responsibilities
- Conduct comprehensive assessments of pediatric patients to identify medical, behavioral, educational, and psychosocial needs.
- Develop, implement, and continuously evaluate individualized transition care plans in collaboration with families, physicians, school personnel, and ancillary providers.
- Coordinate transitions from inpatient hospital settings to home, outpatient, rehabilitative, school-based, or specialty pediatric care.
- Monitor patient progress, adjust care plans as clinical needs evolve, and document all encounters in compliance with HIPAA and agency standards.
- Leverage and expand an existing referral base across New Jersey hospitals, pediatric medical practices, specialty providers, and school districts.
- Build and maintain trusted relationships with discharge planners, social workers, pediatricians, school nurses, IEP/504 teams, and child study teams.
- Represent the organization at community events, school meetings, hospital rounds, and provider in-services to grow visibility and referral volume.
- Track referral sources, conversion rates, and outcomes; report regularly to leadership.
- Educate families on diagnoses, treatment plans, available services, and insurance/benefit navigation (Medicaid, NJ FamilyCare, private insurance).
- Advocate for patient access to appropriate medical, therapeutic, behavioral health, and educational supports.
- Provide culturally competent, family-centered care to a diverse pediatric population.
- Ensure all care management activities comply with NJ state regulations, payer requirements, and agency policies.
- Maintain accurate, timely documentation in the electronic health record or care management system.
- Participate in interdisciplinary case reviews, quality improvement initiatives, and continuing education.
Benefits
- Medical, dental, and vision insurance.
- 401(k) with employer match.
- Paid time off, holidays, and CEU/licensure reimbursement.
- Mileage reimbursement and flexible/hybrid schedule.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Upload and Match Resume
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
