RHTP Navigator

The RHTP Navigator will serve as a frontline, community-based member of a Local Community Hub within Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. Local Community Hubs are county-level care coordination entities that bring together hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), behavioral health providers, pharmacies, Emergency Medical Services (EMS), local public health agencies, and community-based organizations to coordinate clinical, behavioral, and social care for rural residents. Reporting to the Hub Program Manager, the RHTP Navigator is responsible for ensuring residents successfully connect to and complete needed clinical, behavioral, and social services by conducting structured screening, initiating and managing referrals, and addressing barriers to care.  

This role is designed around the specific functions Missouri’s Hubs are expected to deliver: connecting local residents to health and social services, managing referral pathways, supporting provider care coordination, addressing non-clinical barriers, and contributing frontline insights that improve Hub operations over time. The Navigator works across healthcare and community settings to connect residents to appropriate clinical, behavioral, and social services and resolve barriers to access and follow-through. Using the Community Information Exchange (CIE) and other Hub systems, the Navigator documents screenings, tracks referrals, and verifies service completion, escalating issues that remain unresolved.

The Navigator will work across hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS/community paramedicine teams, local public health agencies, schools, and community-based organizations and will support care plan adherence, facilitate handoffs, and help residents navigate fragmented systems. The role also contributes frontline insights on recurring barriers and service gaps to inform Hub operations and local program improvements.

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 according to established Hub protocols.

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 
• Other duties as assigned