Pediatric and Family Nurse Navigator; RN

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Community Health and Dental Care, Inc., Pottstown, PA, US

2 days ago Requisition

Salary Range: $93,000.00 To $99,000.00 Annually

The Pediatric & Family Nurse Navigator (RN) serves as a key member of an interdisciplinary care team dedicated to improving health outcomes for children and youth with special health care needs (CYSHCN). This position provides comprehensive nursing care, care coordination, family support, health education, and resource navigation for pediatric patients from birth through age 18.

Working collaboratively with pediatric providers, case managers, behavioral health professionals, community organizations, and family caregivers, the Nurse Navigator helps ensure that vulnerable children receive timely access to medical, behavioral health, developmental, and social support services. The role includes office-based care coordination as well as home visits designed to reduce barriers to care, support telehealth services, and improve family engagement.

As a participating Community Health Center (CHC) in the Title V CYSHCN initiative, the Nurse Navigator is responsible for supporting children and families in achieving their health goals while promoting dignity, autonomy, family-centered care, and full participation in their communities.

Education:

Graduate of an accredited nursing program.
Associate Degree in Nursing (ADN) required;
Bachelor of Science in Nursing (BSN) preferred.

Licensure:
Current Registered Nurse (RN) license in Pennsylvania.
Current CPR/BLS certification.

Experience:

Minimum of 2 years of pediatric nursing experience preferred.
Experience in care coordination, case management, community health, home health, pediatric primary care, or population health strongly preferred.
Experience working with children and youth with special health care needs, developmental disabilities, or behavioral health conditions preferred.

Attendance required at assigned CHDC site(s) as needed or required.

Coordinate and manage referrals for pediatric patients ages 0-18 receiving services related to:

• Primary care
• Behavioral health and mental health needs
• Developmental concerns and disabilities
• Specialty care services
• Community-based support programs

• Collaborate with pediatric providers, case managers, behavioral health professionals, specialists, schools, and community agencies to develop and implement individualized care plans.
• Facilitate communication among patients, families, providers, and community organizations to ensure continuity of care.
• Monitor referral completion and follow-up activities to address gaps in care.
• Assist families in navigating complex healthcare systems and accessing available resources.

• Conduct nursing assessments in office or in home setting.
• Obtain and document vital signs and physical assessment findings.
• Perform medication reconciliation and identify medication-related concerns.
• Support telehealth primary care visits by providing in-home clinical assistance and patient assessment during encounters with primary care providers.
• Assist with preventive health screenings and health monitoring activities.
• Identify changes in patient condition and communicate findings to the care team.
• Support chronic disease management and ongoing care plan implementation.

Provide patient, caregiver, and family education regarding:

• Medical conditions
• Medications
• Developmental and behavioral health concerns

• Empower families to actively participate in healthcare decision-making.
• Promote self-management skills and health literacy among patients and caregivers.
• Advocate for family-centered, culturally responsive care.

• Assess social determinants of health and identify barriers impacting access to care.
• Connect families with community resources and support services, including:
  • Educational resources
  • Behavioral health services
  • Developmental programs
  • Transportation assistance
  • Financial assistance programs
• Collaborate with community partners to address unmet needs and improve family support.

• Support the goals and objectives of the Title V Children and Youth with Special Health Care Needs initiative.
• Provide comprehensive services that help children and youth with special health care needs play, learn, develop, and thrive.
• Ensure services reflect principles of dignity, respect, autonomy, inclusion, and community participation.
• Partner with families to address social, emotional, developmental, and healthcare needs.
• Promote equitable access to healthcare and supportive services.

• Combination of office-based and community/home-based services.
• Frequent…