RHTP Navigator

OCH•Sparta, MO

21h

About The Position

The RHTP Navigator is a non-clinical, frontline community-based member of a Local Community Hub in Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. The role connects residents with appropriate clinical, behavioral, and social services and helps resolve barriers to access and follow-through. The Navigator works across homes, clinics, hospitals, schools, pharmacies, EMS and community paramedicine sites, local public health agencies, and partner organizations in the assigned Hub geography. Sparta Clinic is the home base, with frequent local travel to surrounding clinics and throughout the assigned Hub counties of Taney, Stone, Christian, and Webster. The Navigator conducts structured screenings, manages and tracks referrals through the Community Information Exchange (CIE) and other Hub-approved systems, verifies service completion, supports care-plan adherence, facilitates handoffs, and escalates unresolved issues. The role engages residents through calls, field visits, community outreach, and partner-site follow-up; maintains an assigned caseload; and contributes frontline insights to improve Hub workflows and local programs. The Navigator does not diagnose, prescribe, or provide licensed clinical treatment, and escalates urgent medical, behavioral health, or safety concerns according to established 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.
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.
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 such as a 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 ability to build trust with patients, families, providers, and community organizations.
Ability to work independently in community-based field settings, including travel between homes, clinics, and partner sites.
Successful background check results are required; screening may include checks involving a candidate’s name and/or fingerprints and other screenings as needed.

Nice To Haves

Formal Community Health Worker (CHW) training or 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 referrals, track service completion, and document outcomes.
Experience in 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 and child populations, pediatric populations, people 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, or other community-based behavioral health support approaches.
Experience supporting access to transportation, food and nutrition programs, home safety, preventive screenings, or telehealth.
Relevant frontline credentials in addition to CHW experience, 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.

Responsibilities

Conduct standardized screening and intake to identify clinical, behavioral, and social needs, and document findings, referrals, and follow-up in the CIE and other Hub-approved systems.
Manage closed-loop referrals and warm handoffs across Hub partners; 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, including primary care, behavioral health, women’s health and prenatal care, EPSDT services, chronic disease management, healthy homes services, home visiting, pharmacy-based services, telehealth, and non-emergency medical transportation.
Identify, prioritize, and address barriers to care such as appointment scheduling, transportation, medication access, benefits or insurance issues, food and nutrition supports, and digital access; escalate recurring or complex barriers as appropriate.
Manage an assigned caseload and provide structured follow-up until services are completed, needs are resolved, or care is appropriately transitioned; document outreach, referral status, service completion, and barriers requiring further action.
Participate in 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, and 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.
Use multi-channel outreach and partner coordination to re-engage residents who are difficult to reach or who do not complete referred services.
Maintain a visible community presence through outreach, partner-site engagement, and local events to build awareness of Hub services, strengthen referral relationships, and support resident trust.
Perform other duties as assigned.