Maternal Health Navigator

Reid Health

3d•Hybrid

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. The Maternal Health Navigator provides patient-centered navigation, care coordination, education, risk screening, home visiting, telehealth support, and referral services for pregnant and postpartum patients. Working in collaboration with OB/GYN providers, social work, community health workers, and community partners, the position helps reduce barriers related to medical, behavioral health, transportation, financial, educational, and other social needs. The Navigator conducts and coordinates prenatal and postpartum home visits; monitoring identified risks; assisting with remote patient monitoring when appropriate; and facilitating timely follow-up or escalation of care. This role complements the care provided by physicians, midwives, advanced practice providers, or other licensed professionals and practices within established protocols and scope of practice. 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.

Requirements

Associate degree in Nursing from an accredited nursing program for candidates serving in the RN Navigator capacity; or Bachelor’s degree in Social Work from an accredited program for candidates serving in the Social Work Navigator capacity.
One year of experience in nursing, social work, care coordination, case management, patient navigation, community health, behavioral health, public health, or a related health or human services field.
Current, unrestricted Registered Nurse license in the state of Indiana (for RN Navigator).
Current Indiana social work license appropriate to the position, such as Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW), as applicable to assigned duties (for Social Work Navigator).
Ohio licensure must be obtained within 90 days of hire or transfer when required for the assigned service area.
Current Basic Life Support certification for RN candidates.
CPR certification appropriate to the position and maintained according to organizational requirements.
Completion of required Reid Health education, employee health requirements, home-visiting training, safety training, HIPAA training, and competency validation.

Responsibilities

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, including monitoring of blood pressure, glucose, weight, heart rate, and other measures.
Review information according to established protocols, communicate concerning findings to providers, support escalation of care, and document patient follow-up.
Participate in the implementation and coordination of the Healthy Beginnings at Home prenatal and postpartum home visiting model for eligible families.
Connect families with WIC, transportation, food and diaper programs, behavioral health, substance use treatment, lactation support, safe sleep resources, and other community services while tracking program engagement and outcomes.
Screen patients for perinatal mood and anxiety disorders, substance use, and related social needs and provide nonjudgmental education regarding available services.
Coordinate and follow up on referrals to behavioral health, substance use treatment, medication-assisted treatment, peer recovery, and other community supports.
Obtain and maintain applicable CPR and Child Passenger Safety Technician certifications.
Provide or coordinate car seat education, safety checks, installation assistance, infant CPR, and emergency preparedness training for families, caregivers, staff, and community members.
Help plan and participate in health fairs, baby showers, diaper events, car seat events, family resource center programs, school events, and other community outreach activities.
Build relationships with health departments, schools, social service agencies, family resource centers, and other community organizations to increase awareness, enrollment, and access to services.
Document assessments, home visits, telehealth encounters, screenings, risk scores, education, referrals, patient contacts, and follow-up in a timely and accurate manner.
Communicate patient needs with providers and care team members and support transitions among emergency, inpatient, outpatient, home, and community settings.
Participate in performance improvement initiatives related to maternal and infant health, home visiting, patient access, education, care transitions, and community based services.
Track program measures, identify workflow barriers, recommend solutions, and support program evaluation, reporting, policy development, and sustainability planning.