Registered Nurse Care Coordinator - Maternal

About the role

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.

Care coordination

• 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 system for engagement, gestational age and trimester, postpartum follow up, newborn care, well child clinic (WCC) visits, and other program measures, including high-risk medical or psychosocial needs.
• 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, including 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.
• Complete 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.
• Support the patient and family in their spiritual wellbeing with the Traditional Health team.
• Participate in community education presentations, CPS and ICWA meetings, as needed.

Nurse-led maternal and child health services

• 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 on 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, including 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.

Interdisciplinary collaboration and general nursing responsibilities

• Work collaboratively with nursing supervisors, nursing staff, medical providers, and medical assistant (MA) team to ensure that direct patient care is managed in a timely and efficient manner and assist as needed in clinic nursing responsibilities.
• Demonstrate understanding of cultural, spiritual, historical, social, and population-specific characteristics that may affect the healthcare needs of the community.
• Coordinate with Traditional Healing to aid in holistic patient care.
• Respond to medical emergencies and incidents as guided by clinic policy and protocols.
• Assist as needed in the maintenance of the crash cart, medication disposal program, sample medications, and patient medications for unhoused patients.
• Document and route patient phone calls and walk-ins to appropriate medical provider and communicate abnormal lab results per protocol.
• Attend regular meetings with Medical Director, OB providers, medical providers, and nursing leadership, and other coordinators for program planning, initiatives, and case management; participate in work groups as requested.
• Perform other related duties as requested by MCH manager, nursing supervisor, or clinical director.

Requirements

• Current, unrestricted license as a Registered Nurse in the State of Minnesota.
• Associate’s degree in nursing from an accredited nursing program.
• Current Basic Life Support certification.
• At least two years of professional nursing experience.
• Demonstrated ability to conduct nursing assessments, provide patient education, coordinate care, and document services with detailed nursing notes.
• Excellent verbal and written communication.
• Ability to work independently and collaboratively with teams, committees, and community partners.
• Strong organizational, problem-solving, critical thinking, and clinical decision-making skills.
• Commitment to patient-centered, trauma-informed care, and harm reduction principles.

Preferred qualifications

• Bachelor of Science in Nursing from an accredited nursing program.
• Public Health Nursing certification, or ability to obtain certification within first year of employment.
• Two or more years of experience in, and care coordination of, obstetric, labor and delivery, postpartum, newborn, pediatric, public health, or maternal-child health nursing.
• Experience caring for individuals with substance use disorders or working with medication-assisted treatment programs.
• Experience working with Native American, tribal communities, or culturally diverse and underserved populations.
• Experience with population health management, grant-funded and health equity programs.

Physical demands and work environment

• Frequently required to stand.
• Frequently required to walk.
• Continually required to sit.
• Frequently required to utilize hand and finger dexterity.
• Frequently required to climb, balance, bend, stoop, kneel or crawl.
• Continually required to talk or hear.
• Frequently required to utilize visual acuity to operate equipment, read technical information, and/or use a keyboard.
• Occasionally required to lift/push/carry items up to 25 pounds.
• Frequently required to lift/push/carry items up to 50 pounds.
• Occasionally required to lift/push/carry items more than 50 pounds.
• Occasional exposure to bloodborne and airborne pathogens or infectious materials.