RHTP Program Navigator

Mosaic Life Care•Maryville, MO

About The Position

The RHTP Program Navigator is a frontline, community-based member of a Local Community Hub in Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. Local Community Hubs coordinate clinical, behavioral, and social care for rural residents across hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS, local public health agencies, and community-based organizations. The Navigator reports to the Hub Program Manager and helps residents connect to and complete needed services through structured screening, referrals, follow-up, and barrier resolution. Working across healthcare and community settings, the Navigator uses the Community Information Exchange (CIE) and other Hub systems to document screenings, manage referrals, track service completion, and escalate unresolved issues. The role supports care-plan adherence, facilitates handoffs, and helps residents navigate fragmented systems. It also contributes frontline observations about recurring barriers and service gaps to improve Hub operations and local programs. 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 under established Hub protocols.

Requirements

High school diploma or equivalent — required.
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 — required.
Valid driver’s license — required upon hire.
Ability to travel between system facilities and off-site locations as needed — required.
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 CIE, EHR, or case management tools.
Ability to manage time and priorities effectively across a field-based caseload and maintain consistent follow-up and coordination.
Ability to work across multiple organizations and disciplines to coordinate services and support continuity of care.
Ability to take ownership of tasks and ensure referrals and services are completed.
Strong verbal and written communication skills and ability to build trust with patients, families, providers, and community organizations.
Persistence in engaging residents and navigating barriers, including repeated outreach when needed.
Practical problem-solving skills to remove barriers to care using available community and provider resources.
Ability to work independently in community-based field settings, including travel between homes, clinics, and partner sites.
Ability to follow standardized workflows and documentation requirements while adapting approaches to individual and community needs.

Nice To Haves

Associate’s degree in Community Health, Public Health, Social Services, Behavioral Health, Human Services, or a related field.
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 conducting resident, client, or patient intake and needs screening and following referrals through to completion.
Experience using a CIE or other closed-loop referral platform to manage referrals, track service completion, and document outcomes.
Experience in a setting 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 or 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, or other community-based behavioral health support approaches.
Experience supporting access to transportation, food/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.
Community Health Worker (CHW) training/certification or related training.

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 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 for review.
Manage an assigned caseload and maintain 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.
Contribute to Hub huddles, case reviews, and partner meetings; support provider coordination and provide 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.
Use multi-channel outreach and partner coordination to re-engage residents who are difficult to reach or 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.