What are the responsibilities and job description for the Torch Anchor Care Navigator position at Bothwell Regional Health Center?
JOB SUMMARY:
The RHTP Navigator reports directly to the Region 6 Program Coordinator.
The RHTP Navigator serves as a frontline, community-based member of a Local Community Hub within Missouri's Rural Health Transformation Program (RHTP) and Transformation of Rural Community Health Care (ToRCH Care) model. The Navigator works across healthcare and community settings to connect rural residents with appropriate clinical, behavioral health, and social services; address barriers to care; coordinate referrals; and support successful completion of services.
The RHTP Navigator conducts standardized screening and intake, manages closed-loop referrals and warm handoffs, maintains an assigned caseload, and provides structured follow-up until identified needs are resolved or care is appropriately transitioned. The Navigator collaborates with hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), behavioral health providers, pharmacies, Emergency Medical Services (EMS)/community paramedicine teams, local public health agencies, schools, and community-based organizations.
The Navigator uses the Community Information Exchange (CIE) and other Hub-approved systems to document screenings, outreach, referrals, service completion, outcomes, and barriers to care. The position also contributes frontline knowledge regarding recurring barriers and service gaps to support Hub operations, referral pathways, and local program improvement.
This is a non-clinical position. The Navigator does not diagnose, prescribe, or provide licensed clinical treatment. Urgent medical, behavioral health, or safety concerns are escalated to appropriate licensed staff or supervisors according to established Hub protocols.
The RHTP Navigator – Region 6 Hub Program Navigator reports directly to the Population Health Director.
QUALIFICATIONS:
Education:
a.) High school diploma or equivalent required.
b.) Formal Community Health Worker (CHW) training/certification or post-secondary education or training in community health, public health, social services, behavioral health, human services, or a related field preferred.
Licensure/Certification:
a.) Valid driver's license required with the ability to routinely travel throughout the assigned multi-county Hub service area.
b.) CHW certification or other relevant frontline credentials, such as Behavioral Health Support Worker, Emergency Medical Technician, Certified Nursing Assistant, or Pharmacy Technician, preferred when applicable.
Work Experience:
a.) 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 required.
b.) Demonstrated experience working directly with rural communities and/or high-need populations and experience conducting intake or needs screening, managing referrals, and maintaining follow-up preferred.
RESPONSIBILITIES/JOB DUTIES:
Conducts standardized screening and intake to identify clinical, behavioral health, and social needs of residents.
Documents screening results, outreach activities, referrals, follow-up, service completion, outcomes, and barriers in the Community Information Exchange (CIE) and other Hub-approved systems.
Manages closed-loop referrals and warm handoffs across Hub partners, including hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS/community paramedicine, public health agencies, schools, and community-based organizations.
Confirms receipt of referred services, documents outcomes, and re-engages residents when referrals or services are not completed.
Engages Medicaid members, dually eligible residents, and other high-need residents through telephone calls, field visits, community outreach, partner-site follow-up, and other appropriate methods.
Provides health education, care navigation, and reinforcement of established care plans within the scope of a non-clinical role.
Assists residents in accessing Hub-supported services, including primary care, behavioral health, women's health and prenatal care, preventive and pediatric services, chronic disease management, healthy homes services, home visiting, pharmacy-based services, telehealth, and non-emergency medical transportation.
Identifies, prioritizes, and resolves barriers to care, including transportation, appointment scheduling, medication access, benefits or insurance concerns, food and nutrition needs, housing or home-related needs, and digital-access barriers.
Escalates complex, unresolved, or recurring barriers to the Hub Program Manager or appropriate supervisor and communicates issues that may require changes to workflows or community resources.
Maintains an assigned caseload and provides structured, timely follow-up until services are completed, identified needs are resolved, or care is appropriately transitioned.
Implements re-engagement strategies for residents who are difficult to reach or who do not complete referred services, using multiple communication methods and coordination with partner organizations.
Facilitates communication and coordination among residents, families, healthcare providers, community organizations, and other service partners to support continuity of care.
Actively participates in Hub huddles, case reviews, partner meetings, and other coordination activities.
Contributes frontline observations and insights regarding recurring barriers, service gaps, referral challenges, and effective practices to support Hub operations and local program improvement.
Tracks and reports outreach, screening, referral, service completion, and outcome data required by the Hub, Regional Care Network (RCN), Rural Health Transformation Office (RHTO), and other applicable program requirements.
Maintains a visible and professional presence in the community through outreach activities, partner-site engagement, local events, and other activities designed to increase awareness of Hub services and strengthen community relationships.
Builds and maintains trusting relationships with residents, families, providers, community organizations, and other partners.
Works independently in community-based settings, including homes, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, public health agencies, and other partner locations.
Escalates urgent clinical, behavioral health, or safety concerns to licensed staff or supervisors in accordance with established Hub protocols.
Maintains confidentiality and follows applicable organizational policies, procedures, documentation requirements, and privacy standards.
REQUIRED STAFF COMPETENCIES:
Demonstrates support for organizational and departmental mission.
Supports and demonstrates knowledge of the Strategic Plan and the Hospital Key Initiatives.
Fosters and promotes teamwork within department and the organization as a whole.
Works to resolves conflicts constructively and in a timely manner.
Ability to communicate effectively and simply with every customer and co-worker.
Ability to display a positive, courteous and friendly attitude toward all contacts.
Ability to build good relationships with others based upon a sustained effort of mutual support toward common goals.
Ability to exercise good judgment, reasoning and concentration to detail and to take personal accountability for all actions in carrying out job duties.
Is customer focused and committed to Quality and Process Improvement with a strong desire to provide service excellence.
Possesses and displays a strong knowledge and understanding of the standards of practice for their position including, if and when applicable, commensurate computer skills; population specific and general competencies; organizational skills, time and project management.
Possesses a vigorous and enthusiastic desire to learn and to grow both personally and professionally, and to improve one's skills in order to deliver the best possible care for our customers.
Performs other duties as assigned.
WORKING CONDITIONS:
This is a community-based position requiring frequent travel throughout the assigned Region 6 Hub geography. Work may occur in residents' homes, healthcare facilities, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, public health agencies, community organizations, and other partner locations.
The position requires regular interaction with residents, families, healthcare professionals, social service providers, and community partners. The Navigator must be able to work independently in varied community environments and maintain professional conduct, confidentiality, and appropriate boundaries.
Frequent local travel is expected most workdays. Occasional evening or weekend outreach may be required based on program activities and community needs.
The employee must be able to safely operate a motor vehicle and maintain a valid driver's license as required for routine travel within the assigned service area.
The RHTP Navigator reports directly to the Region 6 Program Coordinator.
The RHTP Navigator serves as a frontline, community-based member of a Local Community Hub within Missouri's Rural Health Transformation Program (RHTP) and Transformation of Rural Community Health Care (ToRCH Care) model. The Navigator works across healthcare and community settings to connect rural residents with appropriate clinical, behavioral health, and social services; address barriers to care; coordinate referrals; and support successful completion of services.
The RHTP Navigator conducts standardized screening and intake, manages closed-loop referrals and warm handoffs, maintains an assigned caseload, and provides structured follow-up until identified needs are resolved or care is appropriately transitioned. The Navigator collaborates with hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), behavioral health providers, pharmacies, Emergency Medical Services (EMS)/community paramedicine teams, local public health agencies, schools, and community-based organizations.
The Navigator uses the Community Information Exchange (CIE) and other Hub-approved systems to document screenings, outreach, referrals, service completion, outcomes, and barriers to care. The position also contributes frontline knowledge regarding recurring barriers and service gaps to support Hub operations, referral pathways, and local program improvement.
This is a non-clinical position. The Navigator does not diagnose, prescribe, or provide licensed clinical treatment. Urgent medical, behavioral health, or safety concerns are escalated to appropriate licensed staff or supervisors according to established Hub protocols.
The RHTP Navigator – Region 6 Hub Program Navigator reports directly to the Population Health Director.
QUALIFICATIONS:
Education:
a.) High school diploma or equivalent required.
b.) Formal Community Health Worker (CHW) training/certification or post-secondary education or training in community health, public health, social services, behavioral health, human services, or a related field preferred.
Licensure/Certification:
a.) Valid driver's license required with the ability to routinely travel throughout the assigned multi-county Hub service area.
b.) CHW certification or other relevant frontline credentials, such as Behavioral Health Support Worker, Emergency Medical Technician, Certified Nursing Assistant, or Pharmacy Technician, preferred when applicable.
Work Experience:
a.) 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 required.
b.) Demonstrated experience working directly with rural communities and/or high-need populations and experience conducting intake or needs screening, managing referrals, and maintaining follow-up preferred.
RESPONSIBILITIES/JOB DUTIES:
Conducts standardized screening and intake to identify clinical, behavioral health, and social needs of residents.
Documents screening results, outreach activities, referrals, follow-up, service completion, outcomes, and barriers in the Community Information Exchange (CIE) and other Hub-approved systems.
Manages closed-loop referrals and warm handoffs across Hub partners, including hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS/community paramedicine, public health agencies, schools, and community-based organizations.
Confirms receipt of referred services, documents outcomes, and re-engages residents when referrals or services are not completed.
Engages Medicaid members, dually eligible residents, and other high-need residents through telephone calls, field visits, community outreach, partner-site follow-up, and other appropriate methods.
Provides health education, care navigation, and reinforcement of established care plans within the scope of a non-clinical role.
Assists residents in accessing Hub-supported services, including primary care, behavioral health, women's health and prenatal care, preventive and pediatric services, chronic disease management, healthy homes services, home visiting, pharmacy-based services, telehealth, and non-emergency medical transportation.
Identifies, prioritizes, and resolves barriers to care, including transportation, appointment scheduling, medication access, benefits or insurance concerns, food and nutrition needs, housing or home-related needs, and digital-access barriers.
Escalates complex, unresolved, or recurring barriers to the Hub Program Manager or appropriate supervisor and communicates issues that may require changes to workflows or community resources.
Maintains an assigned caseload and provides structured, timely follow-up until services are completed, identified needs are resolved, or care is appropriately transitioned.
Implements re-engagement strategies for residents who are difficult to reach or who do not complete referred services, using multiple communication methods and coordination with partner organizations.
Facilitates communication and coordination among residents, families, healthcare providers, community organizations, and other service partners to support continuity of care.
Actively participates in Hub huddles, case reviews, partner meetings, and other coordination activities.
Contributes frontline observations and insights regarding recurring barriers, service gaps, referral challenges, and effective practices to support Hub operations and local program improvement.
Tracks and reports outreach, screening, referral, service completion, and outcome data required by the Hub, Regional Care Network (RCN), Rural Health Transformation Office (RHTO), and other applicable program requirements.
Maintains a visible and professional presence in the community through outreach activities, partner-site engagement, local events, and other activities designed to increase awareness of Hub services and strengthen community relationships.
Builds and maintains trusting relationships with residents, families, providers, community organizations, and other partners.
Works independently in community-based settings, including homes, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, public health agencies, and other partner locations.
Escalates urgent clinical, behavioral health, or safety concerns to licensed staff or supervisors in accordance with established Hub protocols.
Maintains confidentiality and follows applicable organizational policies, procedures, documentation requirements, and privacy standards.
REQUIRED STAFF COMPETENCIES:
Demonstrates support for organizational and departmental mission.
Supports and demonstrates knowledge of the Strategic Plan and the Hospital Key Initiatives.
Fosters and promotes teamwork within department and the organization as a whole.
Works to resolves conflicts constructively and in a timely manner.
Ability to communicate effectively and simply with every customer and co-worker.
Ability to display a positive, courteous and friendly attitude toward all contacts.
Ability to build good relationships with others based upon a sustained effort of mutual support toward common goals.
Ability to exercise good judgment, reasoning and concentration to detail and to take personal accountability for all actions in carrying out job duties.
Is customer focused and committed to Quality and Process Improvement with a strong desire to provide service excellence.
Possesses and displays a strong knowledge and understanding of the standards of practice for their position including, if and when applicable, commensurate computer skills; population specific and general competencies; organizational skills, time and project management.
Possesses a vigorous and enthusiastic desire to learn and to grow both personally and professionally, and to improve one's skills in order to deliver the best possible care for our customers.
Performs other duties as assigned.
WORKING CONDITIONS:
This is a community-based position requiring frequent travel throughout the assigned Region 6 Hub geography. Work may occur in residents' homes, healthcare facilities, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, public health agencies, community organizations, and other partner locations.
The position requires regular interaction with residents, families, healthcare professionals, social service providers, and community partners. The Navigator must be able to work independently in varied community environments and maintain professional conduct, confidentiality, and appropriate boundaries.
Frequent local travel is expected most workdays. Occasional evening or weekend outreach may be required based on program activities and community needs.
The employee must be able to safely operate a motor vehicle and maintain a valid driver's license as required for routine travel within the assigned service area.