Legacy Community Health Services Registered Nurse –Pediatric High Risk Care Coordinator in Houston (Mapleridge Clinic), Texas

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.

Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to 10 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.

Job Description

The RN –Pediatrics High Risk Care Coordinator is responsible to oversee panel management for the high risk Pediatrics patients of the practice, to monitor high risk medical conditions affecting patient’s care. The RN – Pediatrics High Risk Care Coordinator will work with Care Team Assistants and Medical Director of the practice to develop this position to best serve the needs of the patient panel and the primary care teams.

Essential Functions

  • Work in collaboration with multidisciplinary provider team to provide innovative and evidence-based care;

  • Actively case manage assigned high risk pediatric patients

  • Carefully care-manage all aspects of the patient’s care: referrals to specialists, hospitalizations, ancillary testing, and other enabling services;

  • Anticipate the needs of the patient panel, seeing that necessary documentation is completed or requested before patient visit;

  • Responsible for working with patient and patient’s care team to develop an individualized treatment care plan - including follow-up, labs, and care coordination;

  • Use of technology to assist with all aspects of care: electronic medical record documentation, disease registry, documentation prompts, standing order protocols;

  • Consistently follows all standing orders and uses triage and advice protocols as a guide in assisting patients;

  • Oversees the process of determining the needs of various sets of individuals and creating opportunities for those individuals to achieve optimal health (chronic disease management, wellness promotion, disease prevention, practice population management program) using EHR and registry reporting to determine which patients are overdue for care, services, testing, and/or screening;

  • Oversees the preventive care reminder program for the practice’s patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing, including point of care reminders;

  • Documents all interactions with patient on the EHR progress note template, including providing the patient with a walk-out Plan of Action after the visit;

  • Assist patients family in setting goals for the patient –management, teaching families how to observe and manage tasks for the pediatric patient and report abnormal findings to their physician team;

  • Collaborates with the patient, family, physician, and other care team members in assessing the patient’s progress toward individual health care goals;

  • Assess barriers when patient has not met treatments goals, is not following treatment plan of care, or has not kept important appointments;

  • Leads the physician care teams in ensuring a smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physicians, or by another health care provider;

  • Utilizes community resource list of services available to patients and their families and maintains collegial relationships with community resource agencies used most frequently;

  • Involves patients family in activities to improve their health (patient engagement);

  • Educates patients and their families about health preserving, disease prevention, and disease self-management interventions, creating a collaborative relationship with the patient and their families in the management of their health care status;

  • Educates patients and their families about self-management tasks they can undertake to gain greater control of their health status;

  • Refers patients and their families to other entities for education and as needed

  • Assist the patients family with procurement of medical supplies need to care for the patient when necessary;

  • Contacts the patients family between visits via telephone, email, and/or other to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals;

  • Assists patient care teams with pre-visit preparation for patients in caseload of patients;

  • Orders and arranges for testing and treatment for patients as provided in the Delegation of Clinical Responsibilities Policy (Standing Orders);

  • Oversees the development, procurement, and adoption of patient self-management educational resources used by the practice providers;

  • Participates in the process of incorporating evidenced based diagnosis and treatment guidelines into the care processes in the practice.

  • Works closely with RN-Obstetrics High Risk Care Coordinator to ensure that obstetrical high risk patients as well as their child have continuity of care after delivery.

  • Closely monitor babies that have been in the NICU as well as young mothers and offer education, community resources and agencies if deemed appropriate

Education & Training Requirements

  • State Board recognized nursing education.

  • State of Texas Registered Nursing License

  • Current CPR certified

Work Experience

  • Experience as a licensed, registered nurse, preferred minimum of three (3) years, including home care clinical experience

  • Experience in provision of Primary Care with this population is highly desirable

  • Supports practice mission and goals

  • Bilingual Spanish preferred


  • 9 Holiday + 1 Floating Holiday

  • PTO

  • 403b Retirement Plan

  • Medical / Vision / Dental (if eligible)