Nurse Case Manager - Maternal Health 0783

Cinqcare•1315 Jefferson Avenue, NY

6d•Hybrid

About The Position

Care Medical Practice is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care. 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 participant’s 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.

Requirements

Current unrestricted New York State Registered Nurse license (multi-state license preferred)
Valid driver’s license and auto insurance in nurse’s 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

Nice To Haves

maternal health experience

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 project’s 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
Constitute and coordinate each participant’s 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 Manager’s direction
Coordinate participant educational materials with Program Manager, Director of Maternal Health, and CMO’s support
Report significant medical changes to program physician(s) and director
Correlate and coordinate reports for Project Director