RN Complex Care Manager, Maternal Health - Biltmore Campus (Asheville)

Mountain Area Health Education Center - MAHEC•Asheville, NC

7d•Onsite

About The Position

The RN Complex Care Manager, Maternal Health provides comprehensive care management for high-risk maternal patients throughout pregnancy and the postpartum period, including patients with complex medical conditions, behavioral health needs, and substance use disorders. As a member of the interdisciplinary care team, the RN conducts telephonic and face-to-face assessments, identifies care gaps and barriers, develops individualized care plans, coordinates transitions of care, and provides patient education, medication support, care navigation, and referral coordination. The role emphasizes timely, complex care coordination and postpartum follow-up, care coordination for the mother-newborn dyad, and transitions of both mother and baby to ongoing primary care after the postpartum period. In collaboration with Care Navigators, the RN facilitates access to community-based services and uses risk stratification, population health strategies, and evidence-based interventions to improve maternal and infant outcomes.

Requirements

Current, unrestricted Registered Nurse license in NC or an active multistate license with privilege to practice in NC.
Associate degree in nursing from an accredited nursing program.
Three years of professional nursing experience.
Two years of clinical experience in maternal health, obstetrics, postpartum care, or high-risk maternity.
One year of care management, care coordination, or transitions care management experience.
Excellent skills in Microsoft Office including Word, Excel, PowerPoint, and database applications required.
Excellent verbal and written skills.
Staff must demonstrate appropriate judgment in handling daily assignments.
Must demonstrate appropriate customer service orientation in all interactions within the organization and with patients, co-workers, care providers, and visitors.
Current CPR certification.

Nice To Haves

Spanish speaking skills preferred.
Two years of care management, care coordination, or transitions care management experience.
Bachelor of Science in Nursing.
Experience serving patients with substance use disorders and behavioral health needs.
Experience in ambulatory care, maternal-fetal medicine, population health, or community-based care management.

Responsibilities

Conduct comprehensive care management assessments and screenings and obtain patient consent to participate in the program.
Develop, implement, monitor, and update person-centered care plans in collaboration with patients, providers, and the interdisciplinary care team.
Manage high-risk maternal patients with complex chronic conditions, acute health needs, behavioral health conditions, substance use disorders, and preventive care needs throughout pregnancy and the postpartum period.
Deliver telephonic and in-person triage, clinical support, and care coordination within the RN scope of practice and established protocols.
Review and respond to abnormal test results, execute clinical protocols, and support medication reconciliation, management, and adherence.
Administer and monitor IV infusions and other treatments as applicable to clinic operations.
Recognize and respond appropriately to urgent and emergent patient care situations.
Provide patient education using evidence-based, culturally responsive approaches and teach-back methods.
Maintain accurate, timely, and complete documentation in the electronic health record.
Coordinate care for high-risk maternal patients throughout pregnancy, delivery, and the postpartum period.
Ensure timely prenatal and postpartum follow-up, including follow-up for pregnancy-related medical, behavioral health, and substance use conditions.
Coordinate transitions of care following hospitalizations, emergency department visits, labor and delivery encounters, postpartum discharge, and other care settings.
Identify gaps in care and barriers to treatment and coordinate appropriate interventions and referrals.
Support the transition of mothers from postpartum obstetric care to ongoing primary care.
Facilitate the newborn’s connection to family medicine primary care and support timely newborn and well-child follow-up.
Coordinate care for the mother-newborn dyad to promote continuity, prevent gaps in care, and improve maternal and infant outcomes.
Identify social determinants of health and collaborate with Care Navigators to facilitate referrals and access to community-based services.
Build and maintain an assigned panel of high-risk maternal patients through outreach, enrollment, engagement, and ongoing follow-up.
Use risk stratification and clinical judgment to prioritize patient outreach and care management interventions.
Track, report, and monitor care management activities, quality measures, program outcomes, and care-gap closure.
Promote patient engagement, self-management, and appropriate utilization of healthcare services across the continuum of care.
Participate in and facilitate interdisciplinary care team meetings and complex case reviews.
Educate providers, clinical staff, and care team members regarding care management services, patient eligibility, referral processes, and best practices.
Collaborate with Quality Improvement, Billing, and Audit teams to support regulatory compliance, value-based care initiatives, documentation requirements, and program performance.
Identify operational barriers and collaborate with internal departments, Care Navigators, and community-based services to improve patient access and outcomes.
Serve as a clinical resource and mentor for care team members.
Perform other duties, including telecommuting, as required to support patient care and operational needs.