Position Overview

Work involves the responsibility for the assessment of high risk pregnancies and following them through the postpartum period. To provide formal case management and coordinate health and social needs and resolutions to promote more desirable pregnancy outcomes and reduce infant mortality. Under general supervision; to provide a variety of services in homes, clinics, and other community sites; to serve as case manager for high risk clients to coordinate specialized clinic activities; to provide preventative services including health assessment, teaching, counseling and referral; and to do other job duties as assigned. High risk factors include: history of preterm birth, history of low birth weight, multiple gestations, fetal complications (diabetes, hypertension, HIV, SLE, Sickle Cell, asthma, seizure disorder, renal disease, substance abuse diagnosis, or mental illness), unsafe living environment (homelessness, inadequate housing, violence, or substance abuse), substance use, tobacco use, missing two or more prenatal appointments without rescheduling, inappropriate hospital utilization, or chronic conditions which may complicate pregnancy. Grade 22

Duties and Responsibilities

• Refer potentially Medicaid eligible high risk pregnant women to prenatal care
• Refer potentially Medicaid eligible high risk pregnant women to Medicaid for eligibility determination
• Contact patients identified as having a priority risk factor through claims data (Emergency department utilization, antepartum hospitalization, utilization of Labor and Delivery triage unit) for referral to prenatal care and assess for care management needs
• Review and enter all initial and follow-up pregnancy risk screenings received from Pregnancy Management Program (PMPs) covered by pregnancy care managers Virtual Health within seven (7) business days of receipt of risk screening forms
• Utilize risk screening data and provider referrals to develop strategies to meet the needs of those patients at highest risk for poor pregnancy outcome
• Accept pregnancy care management referrals from Prepaid Health Plan (PHP), non-PMP prenatal care providers, community referral sources, and patient self-referral, in order to provide appropriate assessment and follow-up to those patients based on the level of need
• Review CCNC data reports as appropriate and available identifying additional pregnancy risk status data
• Conduct a thorough assessment by review of claims history and medical record, patient interview, case review with prenatal care provider, and other methods, on all recipients with one or more priority risk factors on initial or follow-up risk screenings and all recipients directly referred for care management for level of need for care management support. Document assessment findings in Virtual Health. Assessment should be continually updated as new information is obtained
• Assign intensity levels as outlined according to program guidelines, based on level of patient need
• Provide care management services in accordance with program guidelines utilizing those interventions that are most effective in engaging patients and meeting their needs, including telephone outreach, practice encounters, home visits, and/or other interventions needed to achieve care plan goals
• Provide care management services based upon level of need as determined through ongoing assessment of the patient
• Develop patient-centered care plans and document key activities within Virtual Health
• Identify community resources available to meet the specific needs of the population
• Refer identified population to childbirth education, oral health, behavioral health or other needed services reimbursed by Medicaid
• Refer identified population to community resources including lactation, parenting, and other supportive services and classes as available in the community
• Assure the assigned care manager participates in relevant PMP meetings
• Assess and follow-up on compliance with prenatal care plan and other needed clinical services
• Ensure changes in status and compliance with care are communicated to the PMP and other appropriate providers
• Provide education about the importance of and assistance with the scheduling of post-partum visits
• Support 17P treatment through regular outreach and education to patients on 17P treatment and assist patients in arranging to receive 17P injections in accordance with best practices
• Arrange transition from the PMP to a primary care medical home for recipients who continue to remain and/or become eligible for Medicaid beyond the post-partum period
• Review and monitor Virtual Health reports created for the PMP programs to determine individuals at greatest risk
• Participate in pregnancy care management and other relevant meetings at the local network
• Maintain performance measures for pregnancy care management
• Participating in Public Health Preparedness activities as directed by agency management; this nurse will be expected to work as needed during public health emergencies, which may result in extended hours and long work shifts
• Be embedded as Care manager at Harris Women’s for two (2) to three (3) days per week to serve Medicaid patients
• Other duties as assigned by supervisor, Health Director, or Deputy Health Director

Work Schedule

Forty (40) hours per week with the option to work four (4) nine (9)-hour days Monday thru Thursday from 8:00 am until 5:30 pm with thirty (30) minutes for lunch and four (4) hours on Friday from 8:00 am until noon with no lunch; or Monday thru Friday 8:00 am until 5:00 pm with (1) one hour for lunch; based on department needs and supervisor approval. Occasional work in late evenings or weekend work may be required. This position is considered on call for after hour emergencies, outbreaks, etc. The person in this position is required to work nights and weekends when necessitated.

Education and Experience

Bachelor’s degree in social work from and appropriately accredited institution; bachelor’s degree in a human services field from an appropriately accredited institution and one year of directly related experience; bachelor’s degree from an appropriately accredited institution and two years directly related experience; or an equivalent combination of education and experience.

Knowledge, Skills and Abilities

• Considerable knowledge of, and skill in, the application of social work principles, techniques, and practices and their application to individual casework, group work, and community problems;
• Knowledge of the psychosocial, socioeconomic, and behavioral problems and their treatment;
• Knowledge of governmental and private organizations, and community resources and the ability to coordinate these as needed;
• Knowledge of laws, regulations, and policies which govern public health programs;
• General knowledge of medical terminology;
• Considerable knowledge of normal and abnormal physiological development and behavior;
• Working knowledge of prevention, detection, reporting, and treatment of child abuse and neglect;
• Working knowledge of interviewing, counseling, and teaching techniques using Motivational Interviewing;
• Working knowledge of the literature and trends in public health;
• Skill in establishing rapport with a client and applying techniques of assessing psychosocial, behavioral, and psychological aspects of client’s problem;
• Working knowledge of cultural, environmental, sociological, and psychological differences and problems encountered in public health nursing;
• General knowledge of current social and economic problems relating to public health, including health disparities;
• Ability to plan, coordinate, and oversee the work of others;
• Ability to deal tactfully with others and to exercise good judgement in appraising situations and making decisions;
• Ability to work in partnership with patients and with other service providers to elicit needed information;
• Ability to establish and maintain effective working relationships;
• Ability to record accurately services rendered and to interpret and explain records, reports, and medical instructions;
• Adequate computer skills to allow communication, patient record documentation, and accessing of information;
• Ability to assess healthcare needs and develop and implement healthcare plans;
• Ability to learn to provide services independently in homes, clinics, and community sites;
• Ability to communicate effectively in written and verbal form;
• Ability to coach, counsel, teach, and inform clients concerning public health issues;
• Ability to teach and supervise other health professionals and volunteers;
• Ability to deal with sensitivity to the needs of people with different cultural, environmental, and social backgrounds;
• Ability to speak effectively before groups;
• Ability to assess healthcare, physical, and psycho-social needs and implement care plans as needed per program;
• Ability to assess community health needs;
• Excellent computer and data entry skills;
• Ability to write and prepare a variety statistical and other reports, records, and charts;
• Ability to provide confidentiality and observation of HIPAA laws and regulations.
• Participating in Public Health Preparedness activities as directed by agency management; this nurse will be expected to work as needed during public health emergencies, which may result in extended hours and long work shifts