Maternal and Infant Health Program Navigator

Job Description

Job Description:\n\n \n \n The Maternal and Infant Health Navigator (Coordinator) is responsible for coordinating, supporting, and navigating care and services for pregnant individuals, postpartum patients, infants, and families participating in the organization's Pre and Post Natal care.\n The Navigator serves as a central point of coordination between patients, families, clinical6 and external partners. The position helps remove barriers to care and supports patients in successfully accessing prenatal, postpartum, pediatric, behavioral health, social, and community services.\n \n The Navigator provides person-centered, culturally responsive, trauma-informed, and strengths-based navigation throughout the maternal and infant continuum of care. The position is focused on improving access, continuity, engagement, health outcomes, and connections to resources for mothers, birthing individuals, infants, and families.\n This position does not replace or independently perform the clinical functions of physicians, nurses, midwives, behavioral health providers, or other licensed professionals. Instead, the Navigator works as an integral member of the interdisciplinary care team to ensure patients receive the appropriate services, follow-up, education, referrals, and support.\n \n The Maternal and Infant Health Navigator is also responsible for maintaining accurate documentation, tracking program activities and outcomes, supporting grant-required reporting, identifying gaps in services, and helping the organization achieve the goals and measurable objectives established under the Grow Grant.\n ESSENTIAL FUNCTIONS AND RESPONSIBILITIES\n 1. Maternal and Infant Care Navigation\n \n Serve as the primary navigation contact for assigned pregnant, postpartum, maternal, infant, and family populations.\n Conduct outreach to patients identified through referrals, clinical reports, registries, screenings, care gaps, or other approved identification processes.\n Assess patient and family needs and develop an individualized navigation plan in collaboration with the patient and care team.\n Help patients understand their care plan, upcoming appointments, referrals, screenings, and recommended services.\n Assist patients with scheduling and coordinating prenatal, postpartum, pediatric, behavioral health, dental, specialty, and other appropriate appointments.\n Support continuity of care throughout pregnancy, delivery, postpartum, and the infant's first year of life.\n Follow up with patients after missed appointments, hospitalizations, emergency department visits, referrals, or other significant events.\n Identify barriers that may prevent patients from accessing care and work collaboratively with the patient and appropriate team members to resolve those barriers.\n Facilitate communication between patients and members of the healthcare team.\n Coordinate transitions between clinical, community, and social service settings.\n Help ensure patients understand where and how to obtain needed services.\n Provide appropriate reminders and follow-up communications using approved organizational methods.\n \n 2. Maternal Health Support\n The Navigator will support pregnant and postpartum patients with access to appropriate services, including but not limited to:\n \n Prenatal care.\n Postpartum care.\n Pregnancy testing and confirmation.\n High-risk pregnancy referrals.\n Maternal behavioral health services.\n Substance-use treatment and recovery resources when appropriate.\n Nutrition and food assistance. CHW\n Transportation assistance. CHW\n Housing and utility resources. CHW\n Insurance enrollment and renewal assistance.\n WIC and other nutrition resources.\n Family planning and reproductive health services.\n Domestic violence and safety resources, following organizational protocols.\n Childbirth and parenting education.\n Breastfeeding and lactation resources.\n Pediatric and newborn care.\n Dental services.\n Social service resources.\n Community-based maternal health programs.\n Other services identified through patient assessment or the patient's care plan.\n \n The Navigator will coordinate closely with clinical staff when patient needs require medical, behavioral health, or other professional intervention.\n 3. Infant and Family Navigation\n Support families in accessing appropriate services for newborns and infants, including:\n \n Establishing and maintaining a pediatric medical home.\n Scheduling newborn and well-child visits.\n Immunization follow-up.\n Developmental screenings.\n Early intervention referrals.\n Nutrition support.\n Breastfeeding/lactation services.\n Safe sleep education and resources.\n Infant supplies and basic-needs resources.\n Dental services when age-appropriate.\n Behavioral/developmental services.\n Specialty referrals.\n Early childhood education and family support programs.\n Transportation and other access needs.\n Follow-up after emergency department visits or hospitalizations.\n \n The Navigator will help families understand the importance of preventive care and support timely completion of recommended services.\n 4. Screening and Social Determinants of Health\n The Navigator will assist with identifying and addressing social and environmental factors that may affect maternal and infant health.\n Responsibilities may include:\n \n Conducting or supporting approved social determinants of health screenings.\n Identifying barriers related to food, housing, transportation, utilities, employment, childcare, insurance, safety, and other basic needs.\n Documenting identified needs in the appropriate electronic health record or program system.\n Connecting patients with internal and community resources.\n Tracking referrals and following up to determine whether services were successfully accessed.\n Escalating urgent or high-risk concerns to the appropriate clinical or leadership team.\n Maintaining an up-to-date community resource directory.\n Developing relationships with community organizations that serve pregnant individuals, infants, and families.\n \n 5. Patient Outreach and Engagement\n The Navigator will actively engage patients who may be at risk of falling out of care or experiencing barriers to services.\n This includes:\n \n Telephone outreach.\n Text or electronic outreach using approved systems.\n In-person outreach.\n Community-based outreach.\n Appointment reminders.\n Follow-up after missed appointments.\n Follow-up after hospital or emergency department encounters.\n Outreach to patients who are overdue for prenatal, postpartum, pediatric, or other recommended services.\n Re-engagement of patients who have become disconnected from care.\n Outreach to eligible patients identified through grant-related reports or registries.\n \n The Navigator will use a respectful, nonjudgmental, culturally responsive approach to engagement.\n 6. Care Team Coordination\n The Navigator will function as an active member of the interdisciplinary care team.\n Responsibilities include:\n \n Participate in care team meetings, huddles, case conferences, and other meetings as assigned.\n Communicate relevant patient needs to appropriate clinical and operational staff.\n Coordinate with providers, nurses, behavioral health staff, medical assistants, registration staff, care managers, social workers, and other team members.\n Assist with closing identified care gaps.\n Communicate referral status and barriers to the appropriate team members.\n Help establish clear ownership of follow-up activities.\n Support warm handoffs between departments and community partners.\n Escalate clinical or safety concerns according to organizational policy.\n Maintain appropriate boundaries regarding clinical decision-making and scope of practice.\n \n 7. Referral Management and Follow-Up\n The Navigator will coordinate and track referrals to internal and external services.\n Responsibilities include:\n \n Receive or identify the referral.\n Contact the patient and explain the purpose of the referral.\n Identify and address barriers to completing the referral.\n Assist with scheduling when appropriate.\n Provide the patient with necessary information.\n Track referral progress.\n Follow up with the patient and/or referral organization.\n Document the outcome.\n Notify the appropriate care team when the referral is completed, declined, unsuccessful, or requires additional intervention.\n \n The Navigator should strive to ensure referrals do not simply leave the organization without a documented outcome.\n 8. Community Partnerships\n The Navigator will establish and maintain working relationships with community organizations and agencies that support maternal and infant health.\n Potential partners may include:\n \n Hospitals and obstetric providers.\n Pediatric providers.\n Public health departments.\n WIC.\n Early Head Start/Head Start.\n Home visiting programs.\n Food and nutrition programs.\n Housing organizations.\n Transportation providers.\n Behavioral health organizations.\n Domestic violence agencies.\n Substance-use treatment organizations.\n Child development and early intervention programs.\n Faith-based and community organizations.\n Local social service agencies.\n Other organizations identified through the Grow Grant program.\n \n \n The Navigator will maintain current contact information, eligibility requirements, referral processes, and other relevant information for community resources.\n \n 9. Patient Education and Health Promotion\n The Navigator will provide or facilitate approved education related to maternal and infant health.\n Education may include:\n \n Importance of prenatal care.\n Postpartum care.\n Newborn care.\n Pediatric preventive care.\n Immunizations.\n Breastfeeding and lactation support.\n Safe sleep practices.\n Nutrition.\n Parenting resources.\n Infant development.\n Family planning.\n Available community resources.\n Appointment preparation.\n Understanding healthcare services and referrals.\n Health insurance and coverage resources.\n \n The Navigator will reinforce—not replace—education provided by licensed clinical professionals.\n \n REQUIRED QUALIFICATIONS\n Education\n Minimum:\n \n High school diploma or equivalent.\n LPN licensed in Indiana\n \n Preferred:\n \n Associate's or bachelor's degree in one of the following or a related field:\n \n Public Health\n Social Work\n Human Services\n Community Health\n Health Administration\n Nursing\n Maternal/Child Health\n Psychology\n Sociology\n Other healthcare or human services discipline.\n \n \n Equivalent education and relevant experience may be considered.\n EXPERIENCE\n Required:\n \n Experience working with patients, families, community members, or vulnerable populations.\n Experience providing customer service, care coordination, community outreach, patient navigation, social services, or related support.\n \n Preferred:\n \n Experience working with pregnant individuals, postpartum patients, infants, children, or families.\n Experience in an FQHC, community health center, public health department, hospital, medical practice, or community-based organization.\n Experience with care coordination or patient navigation.\n Experience addressing social determinants of health.\n Experience working with Medicaid/uninsured populations.\n Experience with grant-funded programs.\n Experience using an electronic health record.\n Experience documenting patient services and referrals.\n Experience working with community resource networks.\n \n KNOWLEDGE, SKILLS, AND ABILITIES\n The successful candidate should demonstrate:\n Maternal & Infant Health Knowledge\n \n Basic understanding of prenatal, postpartum, newborn, and infant healthcare.\n Understanding of the importance of prenatal and postpartum care.\n Knowledge of community resources supporting mothers, infants, and families.\n \n Navigation Skills\n \n Ability to identify barriers to care.\n Ability to develop practical solutions with patients.\n Ability to coordinate multiple services and referrals.\n Strong follow-up skills.\n Ability to manage an assigned caseload.\n \n Communication Skills\n \n Excellent verbal and written communication.\n Ability to communicate with individuals from diverse backgrounds.\n Ability to explain complex information in understandable language.\n Strong listening and relationship-building skills.\n \n Organizational Skills\n \n Strong attention to detail.\n Ability to prioritize competing responsibilities.\n Ability to manage multiple deadlines.\n Ability to maintain accurate records.\n Ability to independently follow through on assigned tasks.\n \n Technology\n \n Basic computer proficiency.\n Ability to use Microsoft Office or comparable systems.\n Ability to learn and effectively use electronic health records.\n Ability to learn grant reporting and tracking systems.\n \n Problem Solving\n \n Ability to identify barriers and develop solutions.\n Ability to recognize when a situation requires clinical or leadership escalation.\n Ability to work independently while remaining connected to the care team.\n \n BILINGUAL REQUIREMENT\n Bilingual ability in English and Spanish is strongly preferred and may be required depending upon the population served and program needs.\n Bilingual staff must follow organizational requirements regarding qualified interpretation and translation services.\n CERTIFICATIONS\n Preferred or required certifications may include:\n \n LPN or RN\n Patient Navigator certification.\n Community Health Worker (CHW)\n Perinatal or maternal-child health certification.\n CPR/BLS, if required by organizational policy.\n Other certifications relevant to the Grow Grant program.\n \n Certification requirements may be adjusted based upon grant requirements and organizational policy.\n The State of Indiana was awarded funding therefore have listed the below State Disclosure and candidates may ask further questions during interview process.\n Disclosure:This Rural Health Transformation Program is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $206,927,896.80 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.