About Texas Children's Hospital
Founded 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 in conjunction with the team and member/family in internal and external settings.
• 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.
• Participates in planning and coordinating services across the continuum of care and documents this plan in designated systems.
• Ensures for the provision of continuity of care needs as required and serves as advocate on behalf of members and families on an ongoing basis across the continuum of care.
• 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.
• Performs all necessary communication and documentation functions.
• Communicates continually with members/families, caregivers and if indicated, medical providers, health plan staff, ECI or monitoring agencies to promote transparency, accountability, problem solving, self-efficacy as well as facilitate appropriate, timely and cost effective care.
• 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.
• Communicates effectively with CMA and supervisor regarding member information needed to effectively manage member/client data.
• Communicates the successes and challenges encountered and any barriers or critical incidents or potential critical situations regarding Health Plan members or Program Participants to the supervisor in weekly 1:1 meetings or sooner if warranted and during case conferences.
• Utilizes the concepts of reflective practice and motivational interviewing in all aspects of communication with the members and family unit during home visit encounters or phone encounters with the goal to refine and master the technique and skill over time.
• Completes all required health, demographic, nursing assessments, mental health, developmental, and mother-baby dyad behavioral assessments and any other required documentation as scheduled.
• Protects all documentation and member field charts in a method outlined by policy and expected procedural safeguards.
• Documents all activities, interactions, teaching, recommendations, nursing related notes and plans, data collection forms, in the electronic agency, state and national data collection systems (or on paper to be scanned to the electronic record).
• Keeps a detailed, up to date outlook calendar that serves as a means of communication as a field based role.
• Collaborates with community health education/outreach organizations and providers to provide for the overall health promotion of TCHP members.
• Completes home visits as prescribed by the evidence-based model and occasional visits in alternative locations such as clinics, hospitals, or public locations.
• Serves as a liaison with and to community that support low-income populations, women and children’s comprehensive health needs, and community/state benefit eligibility.
• 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 generate referrals for sustainability as well as health promotion, maternal-child well- being, or parenting skills as needed.
• Maintains flexible schedule for travel, some evenings and weekends for member visits, health fairs and member and community educational outreach.
• Educates providers and members to the benefits available through Nurse Family Partnership (a no-cost program for TCHP members).
• Provides education to members regarding the TCHP network, access to physicians and specialists and other providers, TCH IDS and community resources as well as basic health information.
• Participates in group events for TCHP members enrolled in the NFP program that require flexibility in schedule (evenings or weekends) one to two times a year.
• Participates in professional development activities Participates in annual needs assessments, personal reflection throughout the year to accurately assess own learning needs, identify strategies and interventions to meet them and periodically discusses with supervisor.
• Completes all required annual education requirements and an annual interaction event with Members.
• Stays informed of current health care developments 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.
• Establishes and records progress toward annual goals.
• Assists in creating a positive work environment that promotes productivity, mentoring, teamwork and cooperation.
• Elicits and considers differing viewpoints when analyzing issues.
• Recognizes accomplishments of team members.
• Prepares and monitors outcome data to assist in identification of improvement activities/opportunities.
• Arranges and monitors appropriate care and services for the members.
• Assesses the member, child, and family comprehensively considering current medical diagnosis, chronic health conditions, mental health considerations, presence of adequate basic needs/resources and appropriate levels of care when making recommendations for members and assisting in goal setting and establishing minimal expectations
• Identifies and reports member quality of care and/or quality of services issues advocate for member needs by providing ongoing support to TCHP members enrolled in the NFP program related to plan benefits, resource coordination and advocacy for customer service or provider issues.
• 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 and profession in the public health and case management domains, general managed care guidelines, and specifically with complex obstetric, pediatrics , maternal and infant mental health, and crisis management.
• Ability to comprehensively assess member/family medical financial, intellectual, psychosocial, relational needs.
• Must have exceptional verbal, written, critical thinking and problem solving skills.
• Expected to obtain and maintain proficiency in the D.A.N.C.E. certification and exhibit the ability to advance from novice to expert in the use of Motivational Interviewing.
• 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
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