RHTP Health Navigator

Brightli•Hannibal, MO

4d•Hybrid

About The Position

The Rural Health Transformation Program (RHTP) Navigator serves as a frontline, community-based team member within a Local Community Hub as part of 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 better coordinate clinical, behavioral, and social care for rural residents. Reporting to the Hub Program Manager, the RHTP Navigator plays a vital role in helping individuals access the care and resources they need to improve their health and well-being. This position works directly with residents to identify barriers to care, conduct screenings, coordinate referrals, and support follow-through with clinical, behavioral health, and community-based services. As part of the Hub team, the Navigator helps residents successfully navigate healthcare and social service systems by connecting them with local resources, tracking referrals, and ensuring services are received. Using the Community Information Exchange (CIE) and other Hub systems, the Navigator documents screenings, monitors referral outcomes, and escalates unresolved needs when additional intervention is required. This position collaborates with hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS and community paramedicine teams, local public health agencies, schools, and community-based organizations to promote coordinated care and improve access to services. The Navigator also provides valuable frontline insight into recurring barriers and community needs, helping shape Hub operations and local service improvements over time. This is a non-clinical position. The RHTP Navigator does not diagnose, prescribe, or provide licensed clinical treatment. Instead, this role focuses on building relationships, encouraging engagement, supporting care plan adherence, and helping residents overcome challenges that may prevent them from receiving needed services. Any urgent medical, behavioral health, or safety concerns are escalated according to established Hub protocols.

Requirements

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
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
Experience conducting resident, client, or patient intake and needs assessments and supporting referrals through completion
Ability to manage multiple active cases while maintaining organized follow-up and coordination efforts
Experience accurately documenting and tracking activities using digital systems such as a CIE, EHR, or case management platform
Valid driver's license and ability to travel throughout an assigned multi-county service area
Strong communication and relationship-building skills with residents, families, providers, and community organizations

Nice To Haves

Community Health Worker (CHW) certification or related education, training, or certification in community health, public health, social services, behavioral health, human services, or a related field
Experience utilizing a Community Information Exchange (CIE) or other closed-loop referral platform
Experience working within an FQHC, RHC, Critical Access Hospital, behavioral health organization, local public health agency, EMS/community paramedicine program, school-based health setting, pharmacy program, home visiting program, or community-based organization
Experience supporting Medicaid members, dual-eligible residents, maternal-child populations, pediatric populations, individuals with chronic disease, behavioral health populations, or individuals experiencing substance use disorder or OUD-related support needs
Training or experience in motivational interviewing, trauma-informed care, health coaching, benefits navigation, Mental Health First Aid, suicide prevention, or other community-based behavioral health support approaches
Experience connecting individuals to transportation services, nutrition programs, telehealth resources, preventive screenings, or home safety supports
Relevant frontline credentials such as Behavioral Health Support Worker, Emergency Medical Technician (EMT), Certified Nursing Assistant (CNA), or Pharmacy Technician training combined with strong community-based navigation experience
Bilingual skills or demonstrated success serving culturally and geographically diverse rural communities

Responsibilities

Conduct screenings to identify clinical, behavioral health, and social service needs
Connect residents with appropriate healthcare providers and community resources
Initiate, manage, and track referrals through completion
Support residents in overcoming barriers such as transportation, housing instability, food insecurity, limited access to providers, and other social determinants of health
Coordinate care across healthcare providers, behavioral health organizations, public health agencies, schools, EMS teams, and community partners
Facilitate handoffs and communication between organizations to support continuity of care
Utilize the Community Information Exchange (CIE) and other systems to document activities, monitor referrals, and track outcomes
Follow up with residents to encourage engagement and service completion
Identify recurring barriers and service gaps and share insights to support Hub improvements
Escalate urgent medical, behavioral health, or safety concerns in accordance with established protocols