AccessHealth brings together a network of healthcare providers and community partners focused on delivering high-quality care to underinsured and underserved communities. The AccessHealth (AH) Maternal Health Navigator will be part of this multidisciplinary team approach to providing the right care in the right place at the right time. This role is integral to the Managing Abstinence in Newborns (MAiN) program, providing critical support for opioid-affected newborns and their families throughout the care continuum. The AH Maternal Health Navigator requires independent decision-making skills to effectively assist with care coordination of opioid –affected newborns and their families before and after delivery. The AH Maternal Health Navigator will work with patients during hospitalization for the birth of the newborn and after hospitalization in the home setting. This role will work collaboratively with community and healthcare partners in planning wrap around services. AccessHealth is committed to promoting health equity and improving access to quality care for all community members. The Maternal Health Navigator will play a pivotal role in achieving these goals, ensuring that every family receives the support they need during this critical time. SPECIFIC DUTIES AND RESPONSIBILITIES + Identify high-risk participants by participating in hospital rounding to ensure successful transition to the next level of care. + Manage a case load of program participants using a multidisciplinary, multi-sector model. + Assist with the coordination of care for opioid-affected newborns and their families before and after delivery. + Conduct assessments to identify needs and develop individualized care plans using a biopsychosocial approach. + Incorporate all information obtained from assessments and establish a plan of care that will ensure outcomes that result in the participants' increased engagement in their health care, establishment of a medical home, access to medication, decreased inappropriate use of an emergency room for non-emergent care and linkage to all the social supports necessary to manage the participant’s health care needs. + Assist and empower participants to engage in the individualized plan of care by establishing relationships, home visits, extensive follow-up, and providing resources as needed. + Conduct follow-up home visits to support ongoing health needs. + With the support of a multidisciplinary team, guide families through available resources, ensuring they receive appropriate services in a timely manner. + Provide education to include safe sleep and car seat safety checks for the target population. + Evaluate the need for additional childcare/safety equipment and provide assistance as needed. + Participate in multidisciplinary team meetings to share insights and coordination efforts. + Demonstrate the ability to work collaboratively with community and health care partners in planning wrap around services including but not limited to health education, food insecurities, housing and employment. + Participate and engage in outreach activities within the community, which include community screenings and educational events. + Ensure the use of evidence-based, health-literate educational materials and videos. + Assist with data collection and outcome tracking to evaluate program effectiveness. + Participate in quality improvement initiatives to enhance the MAiN program impact. + Facilitate communication and collaboration between healthcare providers, community partners, and families to ensure seamless care transitions. + Document using the approved software in a timely and effective manner adhering to policies and procedures related to HIPAA. + Attend and participate in unit, department, and other meetings as required + Assist with developing a plan for safe care with DSS (Department of Social Services)/SAFY (Specialized Alternatives for Families and Youth) as needed. + Available to teach classes on a variety of topics for participants, healthcare partners, and community partners. + Ensuring a primary care provider directs clinical care models and a navigator communicates relevant assessments and outcomes. + Participates in care planning conferences. + Complete and timely documentation, utilizing identified electronic medical record software. + All interactions require an exemplary level of core customer service skills and competency. + Ensured an active and current professional license, certification or registration is required by the job description. + All other duties as assigned EDUCATION/QUALIFICATIONS Required: + Degree in Nursing (LPN), Social Work, Public Health, or a related field + 2 or more years’ experience in a healthcare setting or 4 years total related experience + Prior experience in community health education or public health is preferred. + Prior experience/strong knowledge of maternal and child health, particularly regarding substance use and its impact on families + Current license is in good standing with the South Carolina Board of Labor and Licensing. Preferred + Bilingual English/Spanish or professional working proficiency in Spanish + Experience in care coordination, case management or community health setting Other: + Personal transportation is required to conduct services, home visits, and transport materials and supplies to service locations throughout the assigned areas. + Valid SC driver’s license in good standing.