Pediatric Transition Care Manager

Job description

Position Summary 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. Key Responsibilities Care Coordination & Case Management: - 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 HIP...