Rural Health Transformation Program (RHTP) Navigator/Community Health Worker

Phelps Health

1d•Hybrid

About The Position

The Rural Health Transformation Program (RHTP) Navigator / Community Health Worker serves as a community-based member of a Local Community Hub within Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. Reporting to the Hub Program Manager, the Navigator screens residents’ needs, coordinates referrals, manages an assigned caseload, and addresses barriers to healthcare, behavioral health, and social services. The Navigator works with healthcare and community partners, documents activities in approved systems, and follows up to confirm service completion. This non-clinical role escalates urgent medical, behavioral health, or safety concerns according to established protocols.

Requirements

Associate’s degree in community health, public health, social services, behavioral health, human services, or a related field required.
Valid driver’s license required, with the ability to travel routinely within the assigned multi-county service area.
Relevant experience in community health, care coordination, case management, patient navigation, behavioral health support, public health outreach, social services, or a related field.
Experience serving rural communities and/or high-need populations, conducting intake and needs screenings, and following referrals through completion.
Demonstrated ability to manage multiple cases, maintain organized follow-up, accurately document activities in digital systems, and communicate effectively with residents and community partners.
Ability to work independently, prioritize competing needs, solve problems, and maintain consistent follow-up.
Ability to communicate effectively and respond appropriately to sensitive situations and urgent concerns.
Ability to use computers and digital documentation systems.
Ability to travel between homes, clinics, and community sites and perform duties involving sitting, standing, and walking during visits and outreach activities.

Responsibilities

Conduct standardized intake and needs screenings; document findings, referrals, and follow-up in approved systems.
Coordinate referrals and warm handoffs among healthcare and community partners, confirming service receipt and documenting outcomes.
Manage an assigned caseload and maintain follow-up until services are completed, needs are resolved, or care is appropriately transitioned.
Engage residents through calls, field visits, community outreach, and partner-site visits; provide health education and reinforce established care plans.
Help residents access primary care, behavioral health, maternal and child health, preventive care, chronic disease support, pharmacy services, home-based services, telehealth, and transportation.
Address barriers involving appointments, transportation, medication access, insurance or benefits, food resources, and digital access; escalate complex or recurring concerns.
Re-engage residents who are difficult to reach or have not completed services through repeated outreach and partner coordination.
Participate in Hub huddles, case reviews, partner meetings, and community events to strengthen relationships and improve referral processes.
Track and report required outreach, screening, referral, and outcome data; share service gaps and escalate urgent medical, behavioral health, or safety concerns according to Hub protocols.
Perform other duties as assigned.