Essential Duties & Responsibilities

In-place clinical visit support 

• Attend in-place visits and provide direct nursing support, including vital signs, and growth measurement 

• Administer immunizations on the AAP schedule, maintain vaccine cold chain in the field, and reconcile immunization records with CHIRP. 

• Deliver caregiver teaching at the point of care (exs: safe sleep, feeding and nutrition developmental enrichment, CPR, infant massage)  

• Conduct telephonic and telehealth follow-up, triage caregiver calls, and escalate clinical concerns to the APP or MD. 

Care planning, referral, and documentation 

• Coordinate with nurse informaticist and providers to maintain the EXCEL care plan for each enrolled infant; updating it after every clinical contact, in the GROW-funded visit planning and outcomes tracking platform. 

• Maintain complete and timely documentation in Heidi and the electronic health record. 

• Initiate and track all referrals (closed-loop referrals) to ensure patients successfully access care. 

Transitions of care and Valcore co-management 

• Contribute to the development of BLOOM–Valcore warm handoff and postpartum co-management protocols. 

• Coordinate warm discharge handoffs with regional delivery hospitals, tertiary hospitals, and neonatal intensive care units so that high-risk newborns enter BLOOM care within 48 hours of discharge or DCS referral. 

• Work alongside leadership to build working relationships and standing communication channels with hospital discharge planners, NICU case managers, and Valcore Health staff that make those handoffs reliable. 

Program support 

• Participate in case reviews with the BLOOM leadership, CMO and the clinical team. 

• Support outreach presentations and workshops to DCS offices, health departments, and maternal-infant providers. 

Qualifications

Required 

• Current, unrestricted Indiana Registered Nurse licensure in good standing. 

• Minimum of two years of nursing experience; pediatric, neonatal, obstetric, maternal-child, or public health nursing experience strongly preferred. 

• Current BLS certification; PALS within 90 days of hire. 

• Valid Indiana driver's license, reliable insured vehicle, and willingness to travel throughout the region 

• Ability to clear DCS background, criminal history, and fingerprint-based checks. 

• Demonstrated ability to work independently and exercise sound clinical judgment in non-traditional settings. 
  

Preferred 

• Hospital discharge planning, NICU, care coordination, or case management experience. 

• Experience serving DCS-involved families, foster care populations, or families affected by substance use disorder. 

• Training in trauma-informed care or motivational interviewing. 

• Home health, home-visiting, or rural health nursing experience. 

Work Environment, Travel & Physical Requirements

• Care is delivered in patient homes, foster placements, residential recovery facilities, and hospital settings; home environments vary widely in condition, accessibility, and safety. 

• Regular regional travel across the seven-county service area, including travel to delivery hospitals and tertiary centers.

• Must be able to transport and carry clinical equipment and supplies, examine infants at floor level, and lift up to 30 pounds. 

infants in BLOOM is an equal opportunity employer. This description reflects the general nature of the work performed and is not an exhaustive list of all duties, responsibilities, or qualifications. 

This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.