RHTP Health Navigator

Job Description:

RHTP Navigator Company:
Centerstone

Location:

Hannibal, MOShift: Full-time, Monday - Friday About the Role The Rural Health Transformation Program (RHTP) Navigator serves as a frontline, community-based team member within a Local Community Hub as part of 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 better coordinate clinical, behavioral, and social care for rural residents.

Reporting to the Hub Program Manager, the RHTP Navigator plays a vital role in helping individuals access the care and resources they need to improve their health and well-being. This position works directly with residents to identify barriers to care, conduct screenings, coordinate referrals, and support follow-through with clinical, behavioral health, and community-based services.

As part of the Hub team, the Navigator helps residents successfully navigate healthcare and social service systems by connecting them with local resources, tracking referrals, and ensuring services are received. Using the Community Information Exchange (CIE) and other Hub systems, the Navigator documents screenings, monitors referral outcomes, and escalates unresolved needs when additional intervention is required.

This position collaborates with hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS and community paramedicine teams, local public health agencies, schools, and community-based organizations to promote coordinated care and improve access to services. The Navigator also provides valuable frontline insight into recurring barriers and community needs, helping shape Hub operations and local service improvements over time.

This is a non-clinical position. The RHTP Navigator does not diagnose, prescribe, or provide licensed clinical treatment. Instead, this role focuses on building relationships, encouraging engagement, supporting care plan adherence, and helping residents overcome challenges that may prevent them from receiving needed services. Any urgent medical, behavioral health, or safety concerns are escalated according to established Hub protocols.

What You'll DoConduct screenings to identify clinical, behavioral health, and social service needs

Connect residents with appropriate healthcare providers and community resources

Initiate, manage, and track referrals through completion

Support residents in overcoming barriers such as transportation, housing instability, food insecurity, limited access to providers, and other social determinants of health

Coordinate care across healthcare providers, behavioral health organizations, public health agencies, schools, EMS teams, and community partners

Facilitate handoffs and communication between organizations to support continuity of care Utilize the Community Information Exchange (CIE) and other systems to document activities, monitor referrals, and track outcomes

Follow up with residents to encourage engagement and service completion

Identify recurring barriers and service gaps and share insights to support Hub improvements

Escalate urgent medical, behavioral health, or safety concerns in accordance with established protocols

Qualifications

Minimum Qualifications 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

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 assessments and supporting referrals through completion

Ability to manage multiple active cases while maintaining organized follow-up and coordination efforts

Experience accurately documenting and tracking activities using digital systems such as a CIE, EHR, or case management platform

Valid driver's license and ability to travel throughout an assigned multi-county service area Strong communication and relationship-building skills with…