Maternal Health Navigator

About the Position

This grant-funded position is authorized in one-year funding periods and is contingent upon continued grant funding, program requirements, and achievement of required outcomes. Grant funding may be renewed for additional periods; however, if funding is not renewed or otherwise becomes unavailable, employment in this position will end at the conclusion of the applicable funding period. Employment with Reid Health is at will, meaning that either the employee or Reid Health may end the employment relationship at any time, with or without notice and with or without cause, subject to applicable law. 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.

Responsibilities

• Provide patient-centered navigation, care coordination, education, risk screening, home visiting, telehealth support, and referral services for pregnant and postpartum patients.
• Work in collaboration with OB/GYN providers, social work, community health workers, and community partners to reduce barriers related to medical, behavioral health, transportation, financial, educational, and other social needs.
• Conduct and coordinate prenatal and postpartum home visits; monitor identified risks; assist with remote patient monitoring when appropriate; facilitate timely follow-up or escalation of care.
• Coordinate prenatal, postpartum, infant, specialty, behavioral health, and community-based services for patients and families.
• Develop individualized care plans, coordinate appointments and referrals, and address barriers such as transportation, finances, housing, food, childcare, technology, and health literacy.
• Conduct and coordinate prenatal and postpartum home visits, including nursing assessments, education, risk screening, care coordination, and follow-up.
• Use telehealth during home visits when appropriate and follow established protocols for patient privacy, safety, professional boundaries, and clinical escalation.
• Complete and document approved maternal, postpartum, infant, behavioral health, substance use, safety, and social determinant screenings.
• Apply established scoring tools, develop follow-up plans, track referrals and outcomes, and escalate urgent or high-risk findings according to policy.
• Provide individualized education regarding prenatal care, postpartum recovery, warning signs, medications, breastfeeding, infant feeding, safe sleep, immunizations, infant development, and preventive care.
• Provide or coordinate childbirth education, newborn education, infant CPR, car seat safety, emergency preparedness, perinatal mental health, and substance use education.
• Educate eligible patients on approved monitoring equipment and telehealth services