Nurse Transition Specialist

3 weeks ago


houston, United States Texas Children's Hospital Full time
Nurse Transition Specialist (RN) - Care Coordination

We are searching for a Nurse Transition Specialist (RN) - Care Coordination - someone to work in fast paced setting responsible for deployment of transition and development of a transition plan for Members aged 15 years and above, promoting quality and efficiency in the delivery of care. Coordination includes securing adult care provider relationships found satisfactory to the Member/LAR. Adolescent transition support for adolescents with special healthcare needs requires developing and maintaining positive relationships with Members and their families, and care providers for both pediatric and adult populations. This position will interact with members, caregivers, specialist and primary care providers as well as ancillary providers and service coordination teams on a daily basis. This position will also be responsible for assessments, coordination activities, referral and linkage to community resources, monitoring and tracking outcomes. Think you have what it takes? * Ability to assess, plan, implement, monitor, and evaluate the options and services required to meet an individual's health needs * Experience to provide comprehensive ongoing case management services 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. * Compassion to assists the member/member's family in coping with illness by optimizing the member's/family's self-care abilities and supporting their consumer rights MINIMUM REQUIREMENTS * Associate's degree in nursing OR Diploma in Nursing OR Bachelor's degree in nursing * Nursing license from Texas Board of Nursing or Nurse Licensure compact * Driver's License (any state) * Auto insurance * Must pass a Motor Vehicle Record (MVR) check demonstrating a clear driving record as defined by the routine driver qualifications outlined in the Texas Children's Fleet Safety Policy and Procedure by the job entry date. * 3 years' pediatric nursing experience PREFERRED REQUIREMENTS * Bilingual (Spanish/English) highly preferred * CHW - Community Health Worker * Experience with local and state programs for children with disabilities or managed care * Clinical experience in home care, case management, managed care, or utilization review RESPONSIBILITIES * Develop and maintain business relationships with percolating providers in adult and pediatric networks * Collaborates with member/LAR and service coordination team to develop, implement and monitor member transition plan * Identifies educational needs with the provider network and initiate educational efforts as needed or upon provider requests to expand capacity of adult network willing to accept transitioning members * Contributes transition goals to the Individual Service Plan in collaboration with the Service Coordination Team * Maintains documentation of internal and external communication with providers * Assists participating providers with referrals to community resources, needed engagement with schools, and / or communication between providers * Clinical liaison responsible for care transitions for territory, while positively impacting patient outcomes. * Provide relevant self-management support for patients with chronic illnesses as identified by clinical teams through inbound and outgoing call management within their scope of practice. * Reviews and interprets all relevant information with Member/family and develops/initiates a transition plan and self-management plan with family. * Conducts transition assessment and plan development for STAR Kids Members beginning at age 15. "As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards. "



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