This site uses cookies. To find out more, see our Cookies Policy

Community Health Nurse in Philadelphia, PA at Public Health Management Corporation

Date Posted: 3/6/2019

Job Snapshot

Job Description

The Community Health Nurse (CHN) works with the Medical Home Community Team (MHCT). The MHCT will develop collaborative relationships with Philadelphia Department of Health, Division of Maternal, Child, and Family Heath and the Pennsylvania chapter of the American Academy of Pediatrics Medical Home Initiative to support existing medical homes to better meet the needs of children ages 0-21 and their families, work directly with families referred by these practices, and assist with recruitment and development of new medical homes in Philadelphia County. The CHN will be required to interface with medical practices, providers, and families of those practices frequently. The CHN will support the team’s efforts to build the capacity of medical homes by helping them to establish referral partnerships with community service providers, provide care coordination and home-visiting services to families with enrolled children, and providing some ongoing case management support. The CHN will perform outreach and care coordination services for individuals and families within the Philadelphia area. Through referrals from medical homes, the CHN assesses, coordinates, refers, and evaluates health needs for children. Additionally he/she provides health education, health promotion, and disease prevention services as needed. The CHN collaborates with other health care, social service, and other agencies to function as an advocate and liaison between families. The CHN will conduct assessments and health screenings, observe behavioral health, communicate with clients and referral sources about child’s progress and health, and make appropriate referrals to community agencies and organizations for services not provided by the program. The CHN must be willing to work a flexible schedule including some evening hours, as requested.


  • Establishes and maintains linkages with medical homes, community health centers, parent advisory groups, social service organizations, educational and legal service agencies, and other support services through effective communication.
  • Conducts home visits to assess actual and potential health hazards, develop individual and community based plans of care, provide health education and promotion services, and provides follow-up visits with families.
  • Collaborates with medical homes staff/providers, advisory committees and referral sources to assess and determine most appropriate practices and resources.
  • Works closely with medical home staff/providers to build their capacity to effectively meet the needs of their consumers.
  • Provides care coordination services to families with the direction of medical home practices.
  • Develops and/or implements new approaches to improve program delivery, content, and/or evaluation to better serve the population.
  • Meets regularly with Program Manager to provide project updates and communicate project successes and anticipated barriers/challenges.
  • Provides updates and discusses barriers/challenges with project team members and partners at all scheduled meetings.
  • Attends regular grantee/partnership, state-wide and national meetings, as needed.
  • Monitors and maintains program materials and supplies to ensure adequate inventory for program needs.
  • Works with Program Manager and team to complete all relevant reports.
  • Conducts in-home activities, including screenings, health promotion activities and education.
  • Maintains accurate and confidential records, and generates data and reports appropriately; Evaluates the effectiveness of services.
  • Provides health related advice and guidance for MHCT staff in efforts to assist with managing cases.
  • Attends the required monthly Maternal, Child and Family Health meetings, and regularly attend the bi-monthly Philadelphia Special Needs Consortium meetings.
  • Keeps abreast of up-to-date work in the medical home field and shares information and resources with staff as appropriate.
  • Reviews and integrates new ideas and concepts with Program Manager and Assistant Director in order to improve project delivery, content, and/or evaluation for target audience.

Health Education and Patient Navigation

  • Organizes all aspects of family and individual health navigation and education.
  • Assists with coordination of parent advisory meetings, including identifying sites, coordinating logistics, and completing appropriate reports.
  • Conducts follow-up vcalls with referral sources.
  • Assesses client and family needs and strengths with input from other team members (nurse, other case managers, program supervisor) and family members.
  • Schedules/coordinates patient/healthcare appointments, including: facilitating connection between patient and current primary care provider or linking patient to a new primary care provider; facilitating transportation to appointment, if needed; and accompanying patient to appointment, if needed.
  • Utilizes/Provides interpretation services during appointments, if needed.
  • Conducts appointment follow-up, if needed, including coordinating/scheduling follow-up services, and providing additional referrals for supportive services


  • Excellent understanding of the health system and community-based organizations in Philadelphia.
  • Ability to establish priorities, and work both independently and in a team environment to meet objectives with minimal supervision.
  • Excellent advocacy, problem solving, conflict resolution, time management and professional communication (written and oral) skills.
  • Excellent interpersonal skills and ability to effectively interface with partner organizations, families, parents, children and community residents.
  • Advanced skills in assessing, developing, implementing, coordinating and evaluating individual and group health education, health promotion and disease prevention services.
  • Detail-oriented, with excellent organizational skills.
  • Proficient in Microsoft office suite.


  • At least three years experience working with diverse populations, low-income individuals, individuals from different backgrounds.
  • Minimum of three years of direct care and/or pediatric home care.
  • Able to make clinical judgement appropriate for clients with minimal clinical supervision.

Education Requirement:

  • LPN licensure, Commonwealth of Pennsylvania, required. RN licensure preferred.
  • Bachelor's degree in nursing preferred. 


  • Commensurate with education and experience.