Registered Nurse Care Coordinator - Maternal

SUMMARY

The Registered Nurse (RN) Care Coordinator supports the assessment, planning, implementation, and evaluation of care for a culturally diverse maternal-child health population. The RN Care Coordinator is primarily responsible for coordinating obstetric and pediatric care for patients throughout pregnancy, perinatal period, postpartum, and the child’s first two years of life.

Working as part of an interdisciplinary team, the RN promotes continuity of care, timely access to service, patient education, and engagement in recommended medical care. The RN collaborates with medical providers, medical and nursing staff, the Parental Advocate, behavioral health and medication assisted treatment (MAT) nurses, doulas, lactation staff, child protective services (CPS) and community partners to address social and medical needs.

The RN also maintains accurate clinical and program documentation and acts in support of the Maternal Child Program Manager with data collection, outcome tracking, and grant-reporting requirements for the Maternal Child Health Program.

• Coordinate care for prenatal, perinatal, postpartum, newborn, infant and pediatric patients enrolled in or receiving services through the Maternal Child Health Program.
• Maintain an organized maternal-child health patient tracking for engagement, gestational age and trimester, postpartum follow up, newborn care, well child clinic (WCC) visits, and other program measures. This includes high-risk medical or psychosocial needs and collaboration with the interdisciplinary team to develop and implement individualized care plans.
• Coordinate appointments, diagnostic imaging, lab appointments, transfers of care, hospital admissions, specialty referrals, hospital discharge follow-up, monitor completion of ordered tests, and other necessary services to promote continuity of care.
• Conduct nurse-led maternal and child health visits in accordance with approved utilization of clinic standing orders, clinical protocols, and provider direction within the RN scope of practice. These visits may include prenatal intake, comprehensive nursing assessment, risk screening, medication reconciliation and refills per protocol, patient education, care plan reinforcement, protocol authorized monitoring and testing, postpartum nursing follow up, newborn nursing assessment, and coordination of recommended care.
• Completes accurate, timely documentation of patient encounters in the electronic medical record, acquiring newborn records, and closing patient OB charts according to clinic protocol.
• Perform other program duties as requested to ensure the delivery of high quality, accessible prenatal care. Maintain current knowledge of evidence based maternal and pediatric nursing practices.

• Coordinate with Parental Advocate to maintain patient educational materials and supplies in clinic:
  Prenatal, postpartum, newborn and child equipment, supplies and handouts.
• Supports the patient and family of their spiritual wellbeing with the Traditional Health team.
• Participate in community education presentations, CPS and ICWA meetings, as needed.

• Complete prenatal intake visits, including health history, medication reconciliation, risk screening, patient education, identification of barriers to care and coordination of recommended services.
• Perform components of routine prenatal, postpartum, newborn, and well-child visits using authorized protocols and standing orders applicable to nursing scope of practice.
• Provide education:
  Pregnancy, fetal development, warning signs, labor and delivery, postpartum recovery, infant care, safe sleep, feeding, lactation, immunizations, child development, and recommended preventative care.
• Collaborate with medication assisted treatment (MAT) program nurses, behavioral health, traditional healing, and prescribing providers to coordinate care for pregnant and postpartum patients.
• Coordination of safe and coordinated transitions between substance treatment using trauma-informed care and harm reduction care principles.
• Complete accurate and timely documentation of the progress of patients through their pregnancy, postpartum, newborn to child healthcare related to grant reporting, program audits, quality reviews and monitoring of maternal-child health outcomes.
• Collaborate with the Parental Advocate to connect patients with appropriate resources:
  Doula services, WIC, Dental care, Lactation support, Transportation and housing coordinators, Project Child and CPS, Minnesota Department of Health (MDH) and Hennepin County, and Indian Child Welfare Act resources and advocacy.

• Works collaboratively with nursing supervisors, nursing staff, medical providers, medical assistant (MA) team, to ensure that direct patient care is managed in a timely and efficient manner and assists as needed in clinic nursing responsibilities.
• Demonstrates understanding of cultural, spiritual,…