About Texas Children's HospitalFounded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.
We are searching for a Nurse Home Visitor, someone who utilizing a collaborative approach, assess, plan, implement, monitor and evaluate the options and services required to meet the mother and baby's needs related to health, psychosocial well-being and economic self-sufficiency . Provides comprehensive ongoing case management services to a specific subset of Texas Children's Health Plan members by coordinating and managing care of high risk members in order to meet multiple service needs across the continuum of care, ensure optimal member outcomes that address quality, service, customer satisfaction and cost effectiveness. Assists the member/member's family in coping with the transition from pregnancy to motherhood and parenting by optimizing the member's/family's self-care abilities and supporting their consumer rights.
Think you’ve got what it takes?
• 3yrs RN comparable RN experience
• Assesses, develops, implements and monitors a comprehensive plan of care including goal setting at each visit and completes all required health, demographic, nursing assessments, mental health, developmental, and mother-baby dyad behavioral assessments, activities, teaching, recommendations, and nurses notes in agency, state, and national data collection systems.
• Proactively identifies first time mothers /members in need of case management through state reports, internal reports, community referrals and other internal TCHP areas referrals.
• Comprehensively assesses member’s (as well as the member’s child’s) biophysical, psychosocial, environmental, needs and benefit eligibility.
• Collaboratively identifies problems/barriers/opportunities for intervention. Facilitates goal setting, resolution and revision of plans on an ongoing basis.
• Routinely assesses member’s status and progress; if progress is static or regressive, determine the reason and proactively encourage appropriate adjustments in the care plan, providers and/or services to promote better outcomes.
• Communicates thoughtfully and effectively with members related to appointments, home or alternate visits, cancellations, re-schedules using approved methods considering HIPAA considerations at all times.
• Provides appropriate communication across all domains including members/families, caregivers and if indicated, medical providers, health plan staff, ECI or monitoring agencies to help facilitate appropriate, timely and cost effective care.
• Utilizes the concepts of reflective practice and motivational interviewing in all aspects of communication with the members as well as during reflective supervision sessions weekly with supervisor.
• Keeps a detailed, up to date outlook calendar that serves as a means of communication as a field based role.
• Partners to provide community education, marketing and outreach for TCHP/Nurse Family Partnership members when needed for community awareness about the NFP program and to help generate referrals for sustainability and caseload management.
• Maintains flexible schedule for travel, some evenings and weekends may be necessary for member visits, health fairs, outreach, or client events.
• Stays informed of current trends in Maternal/Child nursing to provide safe, quality nurse home visiting services includes maintaining required certifications, licenses, or skills check offs and actively participates in shared learning during team based meetings.
• Assists in creating a positive work environment that promotes productivity, mentoring, teamwork and cooperation.
• Participates in NFP team meetings, case conferences, program evaluations and data reviews to provide feedback, assess effectiveness, generate ideas, and develop plans to increase efficiencies and improve quality for both the NFP program and to members/individuals enrolled in the program.
Skills & Requirements
• Bachelor’s Degree in Nursing
• Texas License – RN
• Driver’s License – Any State
• Insurance – Automobile
• 3yrs experience: clinical or public health experience, preferably in Maternal-Child Nursing, Pediatrics, Mental Health, Community Health
Knowledge and Skills
• Skill and proficiency in applying highly technical principles, concepts and techniques central to the nursing process, in the public health and managed care environment, with complex obstetric, pediatric , mental health clients with occasional crisis management.
• Ability to comprehensively assess client and family medical, financial, intellectual, developmental, psychosocial, and trauma histories and overall needs.
• Must be autonomous and comfortable in low-income neighborhoods, and have exceptional time-management, organizational, verbal, written, critical thinking and problem solving skills as well as the ability to maintain a non-judgmental and non-confrontational demeanor at all times.
• Expected to obtain and maintain proficiency in the D.A.N.C.E. and AOP certification and exhibit the ability to advance from novice to expert in the use of Motivational Interviewing. These certifications occur after hire while in the role.
• Must have excellent customer service skills, advanced communication and interpersonal skills with all levels of internal and external customers. This includes medical staff, patients and families, clinical personnel, support and technical staff, outside agencies, and members of the community.
• Bilingual in Spanish and English preferred