About Texas Children's HospitalSince 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years. Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation. To join our community of 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org. At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for the women and children that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization. Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
We are searching for a Nurse Home Visitor, someone who will provide individualized assessment, education, goal setting, care planning, and implementation to monitor and evaluate both a pregnant mother and her child over the course of 2+ years. The nurse will provide options and services required to meet the mother and baby's needs related to health, psychosocial well-being and economic self-sufficiency . The nurse provides comprehensive ongoing case management services to a specific subset of Texas Children's Health Plan members (first-time, low income mothers) by coordinating and managing care of high risk members in order to meet multiple service needs across the continuum of care, address quality, service, customer satisfaction and cost effectiveness. Assists the member/member's family in coping with the transition from pregnancy to motherhood and positive parenting by optimizing the member's/family's abilities and supporting their consumer rights.
Think you’ve got what it takes?
• Primarily Weekdays with some evenings required
• 3yrs Pediatrics experience preferred
• visits are virtual—but we will go back to “in home” visits in the near future
• OB/Pediatric, Maternal Child, Public Health, Women's Health, Neonatal, L&D, Mother Baby experience preferred
• Coordinating experience helpful when assisting patients with reaching out to various resources
• EXCELLENT Organizational and Time management skills are required
• 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.
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.
Being fully vaccinated against COVID-19, including any booster dose(s) of the Covid-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.
Skills & Requirements
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 and problem solving
• 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