Registered Nurse - Care Advocate, Full Time Days

Cape Fear Valley Health

3d•Onsite

About The Position

The Care Advocate serves as the trusted point of contact for pregnant and postpartum patients from enrollment through 12 months postpartum. This role integrates empathetic engagement, brief clinical assessment within scope of practice, education, proactive care coordination, and consistent communication with OB, pediatrics, primary care, behavioral health, and community partners.

Requirements

Associates Degree in Nursing required
Current Registered Nurse licensure in North Carolina or Compact state licensure required
2 years of experience in obstetrics, maternal/newborn care, family medicine or pediatrics required
Proficiency in reading, writing and speaking the English language
Proficiency with technology-enabled communication (texting platforms, telehealth) and accurate documentation
Knowledge of SDoH and community resource networks
Demonstrates positive interpersonal skills
Verbal and written skills required
Demonstrates effective organizational and leadership skills
Knowledgeable of the age specific physiological, psychosocial, developmental and spiritual needs of the patients typically served
Speech and auditory acuity for communication of patient needs
Visual acuity for observation of patients
Must be able to lift 35 pounds

Nice To Haves

Bachelors Degree in Nursing preferred
1 year of experience in care coordination, triage nursing, patient education, or case management preferred
1 year of experience with mental health and/or substance use management preferred
Bilingual (English/Spanish) skills preferred
Familiarity with trauma-informed care, health equity principles, and working with diverse populations

Responsibilities

Review automated screening results and relevant EHR information daily.
Conduct clinical assessments (within licensure/scope) related to symptoms, medical follow-up, postpartum concerns, and risk monitoring.
Provide education on prenatal/postpartum self-management, warning signs, chronic disease management (e.g., hypertension), newborn care basics, lactation, and medication adherence as appropriate.
Reinforce provider treatment plans, ensure follow-up appointments, and coordinate communication across OB, pediatrics, primary care, behavioral health, and specialty services.
Triage medical issues; escalate behavioral health/SUD/social risk issues to MSW/LPC partners and escalate emergencies per SOPs.
Complete warm handoffs; schedule internal/external appointments; ensure appropriate consent and information exchange.
Confirm engagement with referrals; troubleshoot barriers; re-engage as needed.
Document assessments, education, plan updates, and follow-ups in the program platform and per site EHR standards.
Communicate promptly with clinical teams about medical concerns, risk changes, or updates using closed-loop communication.
Maintain accurate logs and dashboards for fidelity and monitoring.
Contribute to building and updating the site resource library; tailor resource lists to geography and patient preferences.
Collaborate with the H4MAB Team Members, clinic staff, community partners, and behavioral health partners to support whole-person care.
Participate in onboarding, clinical refresher training, current best-practices training, supervision/case consults, and learning collaborative activities.
Use embedded reports to monitor timeliness, follow-up completion, and referral success; contribute to continuous quality improvement.
Support data quality activities and periodic evaluation.
Other duties as assigned