Perinatal Nurse Case Manager (Hybrid - BSN Required)

Vanderbilt University Medical Center•Nashville, TN

2d•Hybrid

About The Position

The Perinatal Nurse Case Manager supports care coordination and system improvement goals as the nursing component of the care coordination model. The role works to improve outcomes by reducing all-cause hospital readmissions and coordinating episodes of care for patients in a defined population or disease process. Responsibilities include identifying appropriate patients, encouraging patient and family engagement in self-care, supporting warm handovers to the next level of care, educating patients and families on personal care plans using teach-back, conducting follow-up calls, and helping patients navigate the healthcare system. The position is part of Team Firefly, an outpatient clinical program at VUMC providing comprehensive, multidisciplinary care to pregnant and postpartum women with substance use disorder. Firefly offers prenatal and postpartum care, social work and peer recovery support, lactation and pediatric services, collaborative mental health care, intensive outpatient programming, group therapy, and health-related social needs support, including transportation, clothing, food, and diapers. The program supports women in recovery and their families through holistic, trauma-informed care. The nurse coordinates evaluation and care planning for the defined patient population, collaborates with clinical teams and providers, leads patient care coordination meetings, supports transitions between care settings, and contributes to patient education and quality improvement. The role also applies evidence-based practice and advanced nursing assessment and education skills. It requires a Bachelor of Science in Nursing and registered nurse licensure, with five years of experience indicated.

Requirements

Bachelor's degree in Nursing.
Registered Nurse licensure.
Five years of experience indicated.
Advanced capability in evidence-based practice, including recognizing, implementing, and evaluating practice changes based on published research.
Advanced capability in patient education and treatment planning across the care continuum.
Advanced capability in nursing patient assessment and evaluation in complex situations.
Intermediate data management capability, including experience with data entry and analysis using REDCap and/or Excel.

Responsibilities

Coordinate the evaluation process for the defined patient population, completing and documenting portions of the evaluation as appropriate and collaborating with team members to ensure required information is complete.
Support patient access by serving as a liaison between referring provider offices and Vanderbilt providers.
Work routinely with the clinical team to develop collaborative care coordination plans for defined care episodes.
Lead patient care coordination meetings.
Establish relationships and clinical pathways with providers and agencies to optimize care for the defined patient population.
Assist in developing and disseminating patient education materials and information.
Assist with the development and implementation of quality improvement projects.
Assist with discharge and transition planning with the multidisciplinary team, engaging outpatient providers and sharing relevant hospital course information, concerns, pending test results, learning needs, and partnership opportunities.
Coordinate handovers among outpatient, inpatient, and regional teams.
Evaluate care coordination practices and support development of evidence-based practice protocols.
Identify appropriate patients, encourage patient and family engagement in self-care management, and help patients navigate the healthcare system.
Provide patient and family education on personal care plans using teach-back and conduct follow-up phone calls.