SUMMARY: The Registered Nurse (RN) Care Coordinator supports the assessment, planning, implementation, and evaluation of care for a culturally diverse maternal-child health population. The RN Care Coordinator is primarily responsible for coordinating obstetric and pediatric care for patients throughout pregnancy, perinatal period, postpartum, and the child’s first two years of life.

Working as part of an interdisciplinary team, the RN promotes continuity of care, timely access to service, patient education, and engagement in recommended medical care. The RN collaborates with medical providers, medical and nursing staff, the Parental Advocate, behavioral health and medication assisted treatment (MAT) nurses, doulas, lactation staff, child protective services (CPS) and community partners to address social and medical needs.

The RN also maintains accurate clinical and program documentation and acts in support of the Maternal Child Program Manager with data collection, outcome tracking, and grant-reporting requirements for the Maternal Child Health Program.

CARE COORDINATION

Coordinate care for prenatal, perinatal, postpartum, newborn, infant and pediatric patients enrolled in or receiving services through the Maternal Child Health Program.
Maintain an organized maternal-child health patient tracking for engagement, gestational age and trimester, postpartum follow up, newborn care, well child clinic (WCC) visits, and other program measures. This includes high-risk medical or psychosocial needs and collaboration with the interdisciplinary team to develop and implement individualized care plans.
Coordinate appointments, diagnostic imaging, lab appointments, transfers of care, hospital admissions, specialty referrals, hospital discharge follow-up, monitor completion of ordered tests, and other necessary services to promote continuity of care.
Conduct nurse-led maternal and child health visits in accordance with approved utilization of clinic standing orders, clinical protocols, and provider direction within the RN scope of practice. These visits may include prenatal intake, comprehensive nursing assessment, risk screening, medication reconciliation and refills per protocol, patient education, care plan reinforcement, protocol authorized monitoring and testing, postpartum nursing follow up, newborn nursing assessment, and coordination of recommended care.
Completes accurate, timely documentation of patient encounters in the electronic medical record, acquiring newborn records, and closing patient OB charts according to clinic protocol.
Perform other program duties as requested to ensure the delivery of high quality, accessible prenatal care. Maintain current knowledge of evidence based maternal and pediatric nursing practices.
Coordinate with Parental Advocate to maintain patient educational materials and supplies in clinic: Prenatal, postpartum, newborn and child equipment, supplies and handouts.
Supports the patient and family of their spiritual wellbeing with the Traditional Health team.
Participate in community education presentations, CPS and ICWA meetings, as needed.

Nurse-Led Maternal and Child Health Services

Complete prenatal intake visits, including health history, medication reconciliation, risk screening, patient education, identification of barriers to care and coordination of recommended services.
Perform components of routine prenatal, postpartum, newborn, and well-child visits using authorized protocols and standing orders applicable to nursing scope of practice.
Provide education: Pregnancy, fetal development, warning signs, labor and delivery, postpartum recovery, infant care, safe sleep, feeding, lactation, immunizations, child development, and recommended preventative care.
Collaborate with medication assisted treatment (MAT) program nurses, behavioral health, traditional healing, and prescribing providers to coordinate care for pregnant and postpartum patients.
Coordination of safe and coordinated transitions between substance treatment using trauma-informed care and harm reduction care principles.
Complete accurate and timely documentation of the progress of patients through their pregnancy, postpartum, newborn to child healthcare related to grant reporting, program audits, quality reviews and monitoring of maternal-child health outcomes.
Collaborate with the Parental Advocate to connect patients with appropriate resources: Doula services, WIC, Dental care, Lactation support, Transportation and housing coordinators, Project Child and CPS, Minnesota Department of Health (MDH) and Hennepin County, and Indian Child Welfare Act resources and advocacy.

Interdisciplinary Collaboration and General Nursing Responsibilities

Works collaboratively with nursing supervisors, nursing staff, medical providers, medical assistant (MA) team, to ensure that direct patient care is managed in a timely and efficient manner and assists as needed in clinic nursing responsibilities.
Demonstrates understanding of cultural, spiritual, historical, social, and population-specific characteristics that may affect the healthcare needs of the community. Coordinates with Traditional Healing to aid in holistic patient care.
Responds to medical emergencies and incidents as guided by clinic policy and protocols.
Assists as needed in the maintenance of the crash cart, medication disposal program, sample medications, and patient medications for unhoused patients.
Documents and routes patient phone calls and walk-ins to appropriate medical provider and communicates abnormal lab results per protocol.
Attend regular meetings with Medial Director, OB providers, medical providers, and nursing leadership, and other coordinators for program planning, initiatives, and case management.
Participates in work groups, as requested.
Other related duties requested by MCH manager, nursing supervisor, or clinical director.

QUALIFICATIONS:

Current, unrestricted license as a Registered Nurse in the State of Minnesota.
Associate’s degree in nursing from an accredited nursing program.
Current Basic Life Support certification.
At least two years of professional nursing experience.
Demonstrated ability to conduct nursing assessments, provide patient education, coordinate care, and document services with detailed nursing notes.
Excellent verbal and written communication.
Ability to work independently and collaboratively with teams, committees, and community partners.
Strong organizational, problem-solving, critical thinking skills, problem solving, and clinical decision-making skills.
Commitment to patients culturally centered, trauma informed care, and harm reduction principles.

Preferred Qualifications

Bachelor of Science in Nursing from an accredited nursing program.
Public Health Nursing certification, or ability to obtain certification within first year of employment.
Two or more years of experience in, and care coordination, of obstetric, labor and delivery, postpartum, newborn, pediatric, public health, or maternal-child health nursing.
Experience caring for individuals with substance use disorders or working with medication-assisted treatment programs.
Experience with working with Native American, tribal communities, or culturally diverse and underserved populations.
Experience with population health management, grant-funded and health equity programs.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

Frequently required to stand
Frequently required to walk
Continually required to sit
Frequently required to utilize hand and finger dexterity
Frequently required to climb, balance, bend, stoop, kneel or crawl
Continually required to talk or hear
Frequently required to utilize visual acuity to operate equipment, read
technical information, and/or use a keyboard
Occasionally/Frequently/Continually required to lift/push/carry items less than 25 pounds/ up to 50 pounds/ more than 50 pounds
Occasionally exposure to bloodborne and airborne pathogens or infectious materials

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