RHTP Navigator Job Description
The Rural Health Transformation Program information provided by the Missouri Department of Social Services is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $216,276,817.66, with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS, or the U.S. Government.
Location: Assigned Missouri rural Hub / county-based service area
Department: DSS / Hub Anchors / ToRCH Care Network – Local Community Hub
Reports to: Hub Program Manager
Position type: Full-time
Facility: Community-based role operating across homes, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, local public health agencies, and partner organizations within the assigned Hub geography
Travel requirements: Frequent travel throughout assigned Hub geography; local travel expected most days
Scheduled hours: Monday through Friday - 8:00am - 5:00pm (times may vary; occasional evening or weekend outreach may be required)
The RHTP Navigator will serve as a frontline, community-based member of a Local Community Hub within Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. Local Community Hubs are county-level care coordination entities that bring together hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), behavioral health providers, pharmacies, Emergency Medical Services (EMS), local public health agencies, and community-based organizations to coordinate clinical, behavioral, and social care for rural residents.Reporting to the Hub Program Manager, the RHTP Navigator is responsible for ensuring residents successfully connect to and complete needed clinical, behavioral, and social services by conducting structured screening, initiating and managing referrals, and addressing barriers to care.
This role is designed around the specific functions Missouri’s Hubs are expected to deliver: connecting local residents to health and social services, managing referral pathways, supporting provider care coordination, addressing non-clinical barriers, and contributing frontline insights that improve Hub operations over time. The Navigator works across healthcare and community settings to connect residents to appropriate clinical, behavioral, and social services and resolve barriers to access and follow-through. Using the Community Information Exchange (CIE) and other Hub systems, the Navigator documents screenings, tracks referrals, and verifies service completion, escalating issues that remain unresolved.
The Navigator will work across hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS/community paramedicine teams, local public health agencies, schools, and community-based organizations and will support care plan adherence, facilitate handoffs, and help residents navigate fragmented systems. The role also contributes frontline insights on recurring barriers and service gaps to inform Hub operations and local program improvements.
This is a non-clinical role. The Navigator does not diagnose, prescribe, or provide licensed clinical treatment. The Navigator builds relationships with residents, supports engagement and follow-through, and escalates urgent medical, behavioral health, or safety concerns according to established Hub protocols.
- Conduct standardized screening and intake to identify clinical, behavioral, and social needs; document findings, referrals, and follow-up in the Community Information Exchange (CIE) and other Hub-approved systems
- Manage closed-loop referrals and warm handoffs across Hub partners, including hospitals, FQHCs/RHCs, behavioral health providers, pharmacies, EMS/community paramedicine, local public health agencies, schools, and community-based organizations; confirm service receipt, document outcomes, and re-engage residents when referrals or services are not completed
- Engage Medicaid members, dually eligible residents, and other high-need residents through calls, field visits, community outreach, and partner-site follow-up; provide health education, care navigation, and reinforcement of care plans
- Help residents access Hub-supported services such as primary care, behavioral health, women’s health and prenatal care, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, chronic disease management, healthy homes services, home visiting, pharmacy-based services, telehealth, and non-emergency medical transportation
- Identify, prioritize, and resolve barriers to care, including appointment scheduling, transportation, medication access, benefits or insurance issues, food and nutrition supports, and digital-access barriers; escalate recurring or complex barriers requiring Hub Program Manager review or broader workflow changes
- Own an assigned caseload and maintain structured follow-up until services are completed, needs are resolved, or care is appropriately transitioned; document outreach attempts, referral status, service completion, and barriers requiring continued action or escalation
- Actively contribute to Hub huddles, case reviews, and partner meetings; support provider coordination and contribute frontline insights to improve referral pathways, workflows, and local program design
- Track and report outreach, screening, referral, and outcome data required by the Hub, RCN, and RHTO; share qualitative insights and best practices with Hub and regional partners
- Escalate urgent clinical, behavioral health, or safety concerns to licensed staff or supervisors according to Hub protocols
- Implement re-engagement strategies,including multi-channel outreach and coordination with partner organizations, for residents who are difficult to reach or who do not complete referred services
- Maintain a visible presence in the community through outreach activities, partner site engagement, and local events to build awareness of Hub services, strengthen referral relationships, and support resident trust
- Other duties as assigned
Minimum qualifications
- High school diploma or equivalent and relevant experience in community health work, care coordination, case management, patient navigation, Medicaid care management, behavioral health support, public health outreach, social services, or a related field
- Demonstrated experience working directly with rural communities and/or high-need populations facing barriers such as transportation limitations, food insecurity, housing instability, low digital access, limited provider access, or fragmented behavioral health services, among others
- Experience conducting resident, client, or patient intake and needs screening and following through on referrals to completion
- Ability to manage multiple active cases and maintain organized follow-up across residents and partners
- Ability to accurately document and track activities using digital systems (e.g., CIE, EHR, or case management tools)
- Valid driver’s license and ability to travel routinely within an assigned multi-county Hub service area
- Strong verbal and written communication skills and the ability to build trust with patients, families, providers, and community organizations
Preferred qualifications
- Formal Community Health Worker (CHW) training/certification or related training, certification, or post-secondary education in community health, public health, social services, behavioral health, human services, or a related field
- Experience using a Community Information Exchange (CIE) or other closed-loop referral platform to manage closed-loop referrals, track service completion, and document outcomes
- Experience in one or more settings central to the Hub model, such as an FQHC, RHC, Critical Access Hospital, behavioral health agency, local public health agency, EMS/community paramedicine program, school-based health setting, pharmacy program, home visiting program, or community-based organization
- Experience serving Medicaid members, dual-eligible residents, maternal/child populations, pediatric populations, individuals with chronic disease, behavioral health populations, or people with substance use disorder or OUD-related support needs
- Training or demonstrated experience in motivational interviewing, trauma-informed care, health coaching, benefits navigation, Mental Health First Aid, suicide prevention training, or other community-based behavioral health support approaches
- Experience supporting access to services such as transportation, food/nutrition programs, home safety, preventive screenings, or telehealth
- Relevant frontline credentials in addition to CHW experience may be helpful, such as Behavioral Health Support Worker, Emergency Medical Technician, Certified Nursing Assistant, or Pharmacy Technician training, when paired with strong community-based navigation experience
- Bilingual skills or demonstrated effectiveness serving culturally and geographically diverse rural communities
Competencies and personal attributes
- Builds and maintains trust with residents to support ongoing engagement and follow-through on services
- Manages time and priorities effectively across a field-based caseload, maintaining consistent follow-up and coordination
- Practical problem-solver who can remove barriers to care using available community and provider resources
- Works effectively across multiple organizations and disciplines to coordinate services and support continuity of care
- Communicates clearly and effectively with residents, families, and professionals across settings
- Follows standardized workflows and documentation requirements while adapting approach to individual and community needs
- Takes ownership of tasks and ensures referrals and services are completed
- Demonstrates persistence in engaging residents and navigating barriers, including repeated outreach when needed
- Works independently in community-based, field settings, including travel between homes, clinics, and partner sites
Note: Lack of post-secondary education will not be used as the sole basis denying consideration to any applicant
Successful background check results are required for employment in this position. This may include background checks involving a candidate's name and/or fingerprints and other screenings as needed for the specific position.
