Perinatal Nurse Case Manager (Hybrid - BSN Required)

Vanderbilt University Medical Center•Nashville, TN

1d•Hybrid

About The Position

The Perinatal Nurse Case Manager supports the nursing component of Vanderbilt Health’s care coordination model and helps achieve financial, satisfaction, clinical, and system-improvement goals. The role improves outcomes by reducing avoidable 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, educating patients and families about 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 Vanderbilt University Medical Center 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 support for health-related social needs, including transportation, clothing, food, and diapers. The program supports women in recovery and their families through holistic, trauma-informed care. The Nurse Case Manager coordinates evaluation and care planning for the defined patient population, collaborates with clinical teams and providers, and supports care transitions across outpatient, inpatient, and regional settings. The position also contributes to patient education, quality improvement, evidence-based protocols, and practice reflection. The role requires a registered nurse license, a bachelor’s degree in nursing, and five years of relevant work experience. The posting identifies the role as hybrid.

Requirements

Registered Nurse licensure.
Bachelor’s degree in Nursing.
Five years of relevant work experience.
Advanced ability to recognize, implement, and evaluate practice changes based on published research, including in complex situations.
Advanced patient education capability across the care continuum, including treatment planning in complex situations.
Advanced patient assessment and evaluation expertise in challenging and complex situations.
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 as appropriate and collaborating to ensure required information is collected.
Support patient access by serving as a liaison between referring provider offices and Vanderbilt providers.
Work routinely with the clinical team to develop a collaborative plan for coordinating patient care through the defined care episode.
Lead patient care coordination meetings and establish relationships and clinical pathways with providers and agencies to optimize care.
Assist with developing and disseminating patient education materials and information.
Assist with developing and implementing quality improvement projects.
Support discharge and transition planning with the multidisciplinary team, engaging outpatient care providers and sharing relevant information such as hospital course, 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.
Help identify appropriate patients, encourage patient and family engagement in self-care management, and support navigation of the healthcare system.
Provide patient and family education about personal care plans using teach-back methodology and follow-up phone calls.
Support warm handovers to the next level of care by providing timely, pertinent information in a standardized manner.