Pediatric and Family Nurse Navigator (RN)

Pediatric and Family Nurse Navigator (RN)

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.

Role Qualifications:

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.

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

Position 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.

Clinical Nursing Services:

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.

Family/Engagement and Education:

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.

Community Resource Coordination:

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.

Title V CYSHCN Program Responsibilities:

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.

Working Conditions:

Combination of office-based and community/home-based services.

Frequent local travel required for home visits and community outreach activities.

Valid driver's license, reliable transportation, and proof of insurance required.

Ability to lift and carry nursing equipment and supplies as needed.

Documentation/Reporting and Quality Improvement:

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.

Additional Responsibilities:

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.

Mission Impact:

The Pediatric & Family Nurse Navigator plays a critical role in improving health outcomes and reducing barriers to care for children and youth with special health care needs. Through nursing expertise, family engagement, care coordination, and community partnerships, this position helps ensure that every child has the opportunity to achieve their fullest potential and grow into a healthy adult.

Organizational:

Adheres to the organization's mission, vision, and values.

Adheres to the organization's policies regarding time and attendance.

Comply with accepted dress code and maintain a professional image.

Demonstrates reliability and trustworthiness.

Manages time and other resources to meet established goals within the agreed time frames.

Demonstrates flexibility in the acceptance and completion of work assignments.

Participates in the department's performance improvement activities.

Maintains patient/employee confidentiality in the management of information.

Observes the Health Care System's compliance policies.

Essential Skills & Experience:

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.

Physical demands & work environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: While performing duties of job, employees are occasionally required to stand; walk; sit, use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms, talk, and hear. Employees must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Mental Demands: Stressful due to time constraints and multiple tasks/procedures occurring at the same time.

Work environment: The noise level in the work environment is usually moderate.

Manual Dexterity Required: Must be able to manipulate small electronic parts and controls.

Compliance Provision:

This

Community Health and Dental Care