RHTP Navigator

Lake Regional Health System Osage Beach, MO, Missouri, United States

RHTP Navigator

The Rural Health Transformation Program information provided by the Missouri Department of Social Services is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $.66, with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS, or the U.S. Government.

Location: Assigned Missouri rural Hub / county-based service area

Department: DSS / Hub Anchors / ToRCH Care Network – Local Community Hub

Reports to: Hub Program Manager

Position type: Full-time

Facility: Community-based role operating across homes, clinics, hospitals, schools, pharmacies, EMS/community paramedicine sites, local public health agencies, and partner organizations within the assigned Hub geography

Travel requirements: Frequent travel throughout assigned Hub geography; local travel expected most days

Scheduled hours: Monday through Friday - 8:00am - 5:00pm (times may vary; occasional evening or weekend outreach may be required)

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.

• Conduct standardized screening and intake to identify clinical, behavioral, and social needs; document findings, referrals, and…