Care Advocate Nurse

Job Overview The Care Advocate serves as the trusted point of contact for pregnant and postpartum patients from enrollment through 12 months postpartum. The role integrates empathetic engagement, brief clinical assessment within scope of practice, education, proactive care coordination, and consistent communication with OB, pediatrics, primary care, behavioral health, and community partners. Key Responsibilities Review automated screening results and relevant EHR information daily. Conduct brief clinical assessments related to symptoms, medical follow‑up, postpartum concerns, and risk monitoring. Provide education on prenatal/postpartum self‑management, warning signs, chronic disease management (e.g., hypertension), newborn care basics, lactation, and medication adherence as appropriate. Reinforce provider treatment plans, ensure follow‑up appointments, and coordinate communication across OB, pediatrics, primary care, behavioral health, and specialty services. Triage non‑emergent medical issues; elevate behavioral health, SUD, or social risk concerns to MSW/LPC partners and manage emergencies per SOPs. Perform warm handoffs; schedule internal/external appointments; ensure appropriate consent and information exchange. Confirm engagement with referrals; troubleshoot barriers; re‑engage as needed. Document assessments, education, plan updates, and follow‑ups in the program platform and per EHR standards. Communicate promptly with clinical teams about medical concerns, risk changes, or updates using closed‑loop communication. Maintain accurate logs and dashboards for fidelity and monitoring. Contribute to building and updating the site resource library; tailor resource lists to geography and patient preferences. Collaborate with community partners and behavioral health partners to support whole‑person care. Participate in onboarding, clinical refresher trainings, supervision/case consults, and learning collaborative activities. Use embedded reports to monitor timeliness, follow‑up completion, and referral success; contribute to continuous quality improvement. Support data quality activities and periodic evaluation. Qualifications Minimum Active RN or LPN license. At least 2 years of experience in obstetrics, maternal/newborn care, family medicine, or pediatrics. Experience in care coordination, triage nursing, patient education, or case management. Familiarity with trauma‑informed care, health equity principles, and working with diverse populations. Proficiency with technology‑enabled communication (texting platforms, telehealth) and accurate documentation. Preferred Experience in community health, mental health, lactation support, perinatal safety, or chronic disease management. Knowledge of social determinants of health and community resource networks. Bilingual skills in English and Spanish. Core Competencies Empathy and cultural humility. Strong clinical assessment and patient education skills. Strong organizational and communication skills. Comfort discussing sensitive topics, including mental health, substance use, intimate partner violence, and social determinants of health. Collaborative spirit and adaptability. Commitment to advancing equity and respectful care. Experience collaborating with continuum care partners—including inpatient case managers, utilization management teams, and community-based organizations. Skill in referring members to disease management and quality improvement or pharmacy programs (e.g., CHF, asthma, DM). Participation in orientation and update seminars for physicians, offices, staff, and employers. Licensure Licensed Practical Nurse (LPN) Education and Experience Required LPN with 4–5 years of clinical experience, including 1–2 years in an IPA, PHO, or HMO setting performing utilization management case management or referral authorization. Knowledge, Skills & Abilities Competent computer navigation skills. Excellent oral, written, and interpersonal communication skills. Strong organizational skills and ability to handle multiple responsibilities. Knowledge of continuous quality improvement principles. Critical thinking skills and ability to analyze complex data sets. Active licensed LPN. Physician Requirements and Working Conditions Ability to work independently. Regional travel for meetings, orientation, and other required activities. Ability to handle stress and high workload volumes. Flexible with work hours, including early evenings until 8 p.m., Saturdays, and on‑call duties. Lifting requirement: Ability to lift up to 35 pounds without assistance; patient lifts over 35 pounds require use of patient handling equipment and at least one other associate when available. #J-18808-Ljbffr