OB Care Coordinator

ESSENTIAL JOB FUNCTIONS:

Utilize the nursing process to assess, plan, implement, coordinate, and evaluate care for obstetric patients.

Hybrid role requiring onsite CVHS Farmville support at least 3-days a week.

Identify and manage high-risk obstetric patients including those with chronic medical conditions, behavioral health concerns, substance use disorders, social determinants of health needs, adolescent pregnancy, advanced maternal age, and previous adverse pregnancy outcomes.

Conduct comprehensive maternal risk assessments and develop individualized care plans.

Provide prenatal and postpartum education, including nutrition, breastfeeding, safe sleep, family planning, warning signs in pregnancy, and newborn care.

Coordinate referrals to Maternal-Fetal Medicine, behavioral health, social work, nutrition services, lactation support, community health workers, and other specialty services.

Monitor compliance with prenatal and postpartum appointments and conduct outreach to patients who miss appointments.

Assist patients with transportation, insurance issues, Medicaid enrollment, WIC enrollment, and access to community resources.

Collaborate with providers to ensure completion of recommended prenatal screenings, laboratory testing, vaccinations, ultrasounds, and postpartum follow-up.

Perform hospital admission and discharge follow-up for obstetric patients and newborns.

Coordinate postpartum follow-up and ensure completion of postpartum visits within recommended timeframes.

Assist with transitions of care between prenatal, delivery, postpartum, pediatric, and primary care services.

Monitor quality metrics related to maternal and infant health, including prenatal care utilization, postpartum visit completion, low birth weight, breastfeeding support, and maternal health outcomes.

Participate in multidisciplinary case reviews and high-risk pregnancy conferences.

Maintain accurate and timely documentation in the electronic medical record. Demonstrate comfort with translation services to assist a non-English speaking population.

Serve as a patient advocate while supporting patient-centered goals and informed decision-making.

Support population health initiatives and quality improvement activities related to women's health and maternal care.

Knowledge and use of the nursing process to assess, plan, implement and evaluate patient care. Have a strong knowledge of clinical aspects of care.

Provide comprehensive case management with a focus on cost saving, continuity, quality and self-management as indicated.

Serve as patient, family, facility advocates while honoring patient choices and setting patient centered goals. Connect patients and families with needed and available community resources. Follow up with clients and agencies as appropriate to document use/success of referral.

Utilizes effective skills in managing, teaching, negotiating and collaborating with multidisciplinary team.

Promotes a team-based patient-centered medical practice model through leadership and practice. Communicates with administrative and provider staff to ensure nursing staff efforts are supporting the model.

Documents in the electronic medical records

Creates care plans for specific populations of patients based on need

Assists with transition of care from hospital discharge to follow-up after visit with PCP

Is responsible for the nursing management of a population of focus, based on the needs of the organization and/or site

May receive referrals from staff within the site, Care Coordinator(s), hospital/insurance staff, the patient and/or caregiver/family

Assists with follow up and scheduling of appointments as needed.

Completes necessary reports and maintains records of data as required.

Acts as the floor nurse for the contracted OB/GYN providers at all assigned locations

Performs other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES:

Valid, unrestricted nursing license.

Registered Nurse, Bachelor’s Degree preferred, in Nursing or related field.

Ability to work independently.

Maintain confidentiality.

Excellent written and verbal communication skills.

Knowledge of community resources and experience with high risk populations.

Knowledge of Medicaid maternity programs, WIC, maternal health quality measures, and community resources.

Ability to work collaboratively with the community, patients, families and other members of health care team.