• Provides for continuity of care by ensuring smooth transitions across the cardio-obstetric care continuum, from prenatal identification through postpartum follow-up. Develops and maintains relationships with patients, obstetric providers, and cardiac care teams to facilitate navigation through diagnosis, treatment, and ongoing follow-up. Personalizes the care coordination approach to maximize service management and patient engagement.
• Identifies and enrolls eligible obstetric patients with known or suspected cardiovascular risk factors or diagnoses into the cardio-obstetric care program. Completes a nursing assessment with a focus on both obstetric and cardiac disease, identifies individualized patient needs, and integrates with obstetrics, cardiology, pharmacy, and ancillary departments to develop a coordinated plan of care. Tracks diagnostic testing and reports through the system to ensure timeliness and follow-through.
• Communicates necessary clinical and care coordination information and collaborates with physicians, advanced practice providers, office staff, hospital departments, and community agencies to ensure continuity across care settings. Serves as the primary point of contact for patients navigating a complex, multidisciplinary care pathway.
• Counsels and educates patients and their family members on cardio-obstetric conditions, risk factors, and disease management. Acts as a consultant, advocate, and point of contact within the healthcare system for the maternal cardiovascular program.
• Supports outreach to rural and remote clinic sites within the middle Georgia service region, coordinating onsite visits and care delivery for patients who face geographic barriers to accessing specialized maternal and cardiovascular services. Travel to remote clinic locations is required on a scheduled basis, expanding in frequency as the program grows.
• Refers patients to appropriate resources including financial counseling, social services, and clinical support programs. Facilitates connection to support services and provides appropriate referrals for patients and family members.
• Evaluates, selects, and designs patient education materials specific to cardio-obstetric conditions and the maternal health program. Provides community education and outreach including health fairs, workshops, seminars, and presentations to both professional and lay audiences. Actively promotes awareness of the program and supports development of referral relationships.
• Maintains accurate and timely clinical documentation in support of monthly Department of Public Health billing cycles and contract compliance reporting. Tracks program metrics and patient outcomes data, contributing to DOH deliverable reporting in alignment with the Maternal Health Rural Contract requirements.
• Participates in the development, implementation, and maintenance of quality programs that include evaluation of costs, patient care outcomes, and patient satisfaction. Utilizes data to implement best practices and identify opportunities for improvement across the cardio-obstetric program.
• Analyzes variances in standard treatment guidelines for cardio-obstetric care to support initiatives that improve quality and efficiency, manage costs, and ensure a systematic approach to the patient's total care.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.
• Certification in Obstetric Nursing (RNC-OB) or a cardiovascular nursing specialty credential preferred.

Education Required:

• Associate's Degree in Nursing required. Bachelor's Degree in Nursing preferred.

Experience Required:

• Typically requires 5 years of experience in clinical nursing, with a focus in obstetric, maternal-fetal medicine, or cardiovascular nursing. Experience in care coordination, clinical navigation, or case management preferred. Familiarity with DOH-funded programs or rural health outreach is a plus.

Knowledge, Skills & Abilities Required:

• Working knowledge of cardio-obstetric care needs and the components of quality care management for maternal and cardiovascular patient populations.
• Excellent analytical and interpersonal communication skills necessary to collaborate with patients, families, physicians, advanced practice providers, and interdisciplinary team members.
• Demonstrated ability to work effectively with physicians and other healthcare professionals in a direct and positive manner across multiple service lines and care settings.
• Ability to manage a complex patient panel independently, prioritize competing demands, and maintain accurate documentation in support of clinical and contractual reporting requirements.
• Demonstrated ability to operate all equipment necessary to perform the job, including computer systems, electronic health records, fax, copier, and standard telephone systems.

Physical Requirements and Working Conditions:

• Manual dexterity required for operation of computer and related equipment.
• Visual acuity required to facilitate review of written documents, computer screens, medical records, and to record information accurately.
• Clear oral communication and hearing acuity required for receiving instructions and conversing on standard telephone and in clinical environments.
• Functional speech and hearing to allow for effective communication of instructions and conversation in person, over the telephone, and in community and clinic settings.
• Ability to travel to rural and remote clinic sites within the middle Georgia service region as required by program schedule.
• Exposed to normal office and outpatient clinical environments.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.