Family Nurse Partnership (RN)

We’re looking for a Nurse Home Visitor for our Nurse Family Partnership. In this position you will assess, plan, implement, monitor and evaluate the options and services required to meet the mother’s and baby’s needs related to health, psychosocial well‑being, and economic self‑sufficiency. The nurse will provide comprehensive, ongoing in‑person case‑management services to Health Plan members by coordinating and managing care of high‑risk members across the continuum of care, ensuring optimal outcomes that address quality, service, customer satisfaction and cost‑effectiveness. Service area is primarily Northwest Harris County (e.g., Jersey Village, Cypress, Spring) but not limited to those locations. The role includes assisting members and families in transitioning from pregnancy to motherhood, optimizing self‑care abilities, supporting consumer rights, and conducting home visits. Women’s services background and bilingual English/Spanish ability are highly preferred.

Responsibilities

• Assess, develop, implement, and monitor comprehensive care plans, including goal setting with the team and member/family in internal and external settings.
• Proactively identify first‑time mothers/members in need of case management through state reports, internal reports, community referrals, and other internal referrals.
• Conduct comprehensive assessments of members (and their children) covering medical, behavioral, and non‑medical drivers of health and benefit eligibility.
• Participate in planning and coordinating services across the continuum of care and document the plan in designated systems.
• Ensure continuity of care and serve as an advocate for members and families on an ongoing basis.
• Identify problems, barriers, and opportunities for intervention collaboratively.
• Facilitate goal setting, resolution, and revision of plans on an ongoing basis.
• Routinely assess member status and progress; intervene when progress is static or regressive by adjusting care plans, providers, or services.
• Perform all required communication and documentation functions.
• Collaborate with community health education/outreach organizations and providers to promote overall health of members.
• Participate in professional development activities.
• Prepare and monitor outcome data to identify improvement activities and opportunities.

Requirements

• Bachelor’s degree in nursing (required).
• Active RN license – Texas Board of Nursing or Nursing Licensure Compact (required).
• Valid driver’s license (any state) and current automobile insurance (required).
• Basic Life Support (BLS) certification – American Heart Association (required).
• Minimum three years of clinical or public‑health experience, preferably in maternal‑child nursing, pediatrics, mental health, or community health (required).
• Successful completion of respiratory fit testing in compliance with occupational health and safety standards (required).

Skills & Qualifications

• Ability to drive and conduct home assessments.
• Strong background in women’s services.
• Bilingual proficiency in English and Spanish is highly preferred.
• Excellent communication, documentation, and collaboration skills.
• Ability to assist families in coping with the transition from pregnancy to motherhood and parenting.
• Commitment to supporting consumer rights and self‑care abilities of members and families.