Nurse Case Manager- Maternal Health
The Nurse Case Manager will lead coordination of Healthy Start (HS) Program participants whole-person care, including (re)assessments, care planning and updates, constituting and coordinating each participants interdisciplinary care team, monitoring information flows for deterioration of participant condition, facilitating transitions of care, and marshaling other HS Team members to provide wraparound perinatal care.
Key Responsibilities:
- Lead the coordination of HS participants whole-person care, including medical, behavioral, and health-related social care
- Partner with the CHW Supervisor to marshal the projects Community Health Workers to facilitate non-clinical care interventions, targeted health education, and social support
- Conduct clinical assessments using evidence-based tools, under the guidance of the Program Manager, Director of Maternal Health, and Chief Medical Officer (CMO)
- Prepare participant-centered care plans
- Constituting and coordinating each participants interdisciplinary care team
- Coordinate and monitor care plan implementation and triage changes in status
- Facilitate transitions of care to and from a higher level of care
- Lead daily huddles and weekly case conferences with Program Manager and Project Director support
- Conduct reassessments and update care plans according to practice standards
- Facilitate participant discharges according to HS program guidelines
- Complete in-home, virtual or telephonic visit as indicated by Program Managers direction
- Coordinate participant educational materials with Program Manager, Director of Maternal Health, and CMOs support
- Report significant medical changes to program physician(s) and director
- Correlate and coordinate reports for Project Director
Required Qualifications:
- Current unrestricted New York State Registered Nurse license (multi-state license preferred)
- Valid drivers license and auto insurance in nurses name as a driver
- Reliable transportation
- Current CPR/BLS certification
- At least 3 years patient care management experience, preferably in an obstetric practice setting (maternal health experience preferred)
- Strong experience with electronic medical records, health information exchanges, coding, and related systems and tools
- Excellent written and verbal communication skills and experience communicating and leading interdisciplinary care teams
- Comfort working in a diverse, fast-paced environment
Our Benefits:
At Care Medical Practice, we care for our team like we care for our patients holistically. We offer flexible, comprehensive benefits so you can thrive while delivering top-notch care. Medical Plans: Two comprehensive options offered to Team members. 401K: 4% employer match for your future. Dental & Vision: Flexible plans with in-network savings. Paid Time Off: Generous PTO, holidays, and wellness time. Extras: Pet insurance, commuter benefits, mileage reimbursement, CME for providers, and company-provided phones for field staff.