RHTP Navigator

FCC Behavioral Health•Poplar Bluff, MO

1d•Hybrid

About The Position

The RHTP Navigator helps rural residents connect to and complete needed clinical, behavioral health, and social services through Missouri's Rural Health Transformation Program and Transformation of Rural Community Health Care network. The Navigator screens for needs, coordinates referrals and warm handoffs, addresses barriers to care, and follows each referral through completion.

Requirements

High school diploma or equivalent.
Relevant experience in community health, care coordination, case management, patient navigation, behavioral health, public health, or social services.
Experience working with rural or high-need populations and helping individuals overcome barriers to care.
Experience completing needs screenings, coordinating referrals, and following up to ensure services are received.
Ability to manage multiple cases and accurately document activities using electronic systems.
Strong communication and relationship-building skills.
Valid driver’s license and ability to travel routinely throughout the assigned multi-county service area.

Nice To Haves

Community Health Worker certification or related training or education in health or human services.
Experience using a Community Information Exchange, electronic health record, case management system, or closed-loop referral platform.
Experience working in healthcare, behavioral health, public health, emergency medical services, schools, home visiting, or community-based organizations.
Experience serving Medicaid recipients or populations with complex health, behavioral health, substance use, or social service needs.

Responsibilities

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.
Adherence to all applicable evidence-based practice models.
Orally communicate information effectively and accurately.
Assure program operates within the constraints of the agency’s certification (CARF, DMH) standards and strategic plan related to clinical care.
Abide by program and agency policies and procedures.
Other job duties and special projects as assigned.