JOB SUMMARY:
The RN Complex Care Manager, Maternal Health provides comprehensive care management for high-risk maternal patients throughout pregnancy and the postpartum period, including patients with complex medical conditions, behavioral health needs, and substance use disorders. As a member of the interdisciplinary care team, the RN conducts telephonic and face-to-face assessments, identifies care gaps and barriers, develops individualized care plans, coordinates transitions of care, and provides patient education, medication support, care navigation, and referral coordination.
The role emphasizes timely, complex care coordination and postpartum follow-up, care coordination for the mother-newborn dyad, and transitions of both mother and baby to ongoing primary care after the postpartum period. In collaboration with Care Navigators, the RN facilitates access to community-based services and uses risk stratification, population health strategies, and evidence-based interventions to improve maternal and infant outcomes.
SPECIFIC RESPONSIBILITIES:
Complex Care Management and Clinical Support
Conduct comprehensive care management assessments and screenings and obtain patient consent to participate in the program.
Develop, implement, monitor, and update person-centered care plans in collaboration with patients, providers, and the interdisciplinary care team.
Manage high-risk maternal patients with complex chronic conditions, acute health needs, behavioral health conditions, substance use disorders, and preventive care needs throughout pregnancy and the postpartum period.
Deliver telephonic and in-person triage, clinical support, and care coordination within the RN scope of practice and established protocols.
Review and respond to abnormal test results, execute clinical protocols, and support medication reconciliation, management, and adherence.
Administer and monitor IV infusions and other treatments as applicable to clinic operations.
Recognize and respond appropriately to urgent and emergent patient care situations.
Provide patient education using evidence-based, culturally responsive approaches and teach-back methods.
Maintain accurate, timely, and complete documentation in the electronic health record.
Maternal, Postpartum, and Newborn Care Coordination
Coordinate care for high-risk maternal patients throughout pregnancy, delivery, and the postpartum period.
Ensure timely prenatal and postpartum follow-up, including follow-up for pregnancy-related medical, behavioral health, and substance use conditions.
Coordinate transitions of care following hospitalizations, emergency department visits, labor and delivery encounters, postpartum discharge, and other care settings.
Identify gaps in care and barriers to treatment and coordinate appropriate interventions and referrals.
Support the transition of mothers from postpartum obstetric care to ongoing primary care.
Facilitate the newborn’s connection to family medicine primary care and support timely newborn and well-child follow-up.
Coordinate care for the mother-newborn dyad to promote continuity, prevent gaps in care, and improve maternal and infant outcomes.
Identify social determinants of health and collaborate with Care Navigators to facilitate referrals and access to community-based services.
Population Health and Patient Engagement
Build and maintain an assigned panel of high-risk maternal patients through outreach, enrollment, engagement, and ongoing follow-up.
Use risk stratification and clinical judgment to prioritize patient outreach and care management interventions.
Track, report, and monitor care management activities, quality measures, program outcomes, and care-gap closure.
Promote patient engagement, self-management, and appropriate utilization of healthcare services across the continuum of care.
Interdisciplinary Collaboration and Program Support
Participate in and facilitate interdisciplinary care team meetings and complex case reviews.
Educate providers, clinical…