Pediatric and Family Nurse Navigator (RN)

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

81d•$93,000 - $99,000•Hybrid

About The Position

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.

Requirements

Graduate of an accredited nursing program.
Associate Degree in Nursing (ADN) required
Current Registered Nurse (RN) license in Pennsylvania.
Current CPR/BLS certification.
Valid driver's license, reliable transportation, and proof of insurance required.
Strong understanding of pediatric growth and development.
Knowledge of community-based healthcare resources and social service systems.
Ability to conduct comprehensive nursing assessments in diverse settings.
Excellent communication and relationship-building skills.
Ability to work effectively with children, families, providers, schools, and community partners.
Strong organizational and care management skills.
Experience with electronic health records and data tracking systems.
Demonstrated commitment to family-centered, trauma-informed, and culturally responsive care.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
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.

Responsibilities

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, Treatment plans, Medications, Preventive care, 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, Social service agencies
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.
Maintain accurate and timely clinical documentation in the electronic health record.
Develop, update, and monitor individualized care plans.
Track patient engagement, services delivered, referral outcomes, and program measures.
Collect and report data required by organizational and grant-related initiatives, including Title V reporting requirements.
Participate in quality improvement activities and performance measurement initiatives.
Assist with outcome tracking and evaluation of program effectiveness.
Participate in interdisciplinary care team meetings and case reviews.
Maintain compliance with organizational policies, nursing standards, and regulatory requirements.
Participate in staff training and professional development activities.
Perform other nursing and care coordination duties as assigned.