CHW

The Rural Health Transformation Program (RHTP) Navigator serves as a frontline, community-based team member within Missouri's ToRCH Care model, supporting a Local Community Hub that coordinates clinical, behavioral, and social services across hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS, public health agencies, schools, and community organizations. Reporting to the Hub Program Manager, the Navigator conducts screenings, manages referrals, addresses barriers to care, and helps residents successfully access and complete the services needed.

Using the Community Information Exchange (CIE) and other Hub systems, the Navigator tracks referrals, verifies service completion, supports care plan adherence, facilitates transitions between providers, and escalates unresolved issues or urgent concerns in accordance with Hub protocols. As a non-clinical role, the Navigator does not provide medical treatment but focuses on resident engagement, care coordination, and identifying service gaps and community needs to support continuous improvement of Hub operations.

• 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; escalations of 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
• Support the Health Center's mission, vision, and values through active participation in organizational initiatives, community-related events, outreach activities, and other efforts that promote access to care and support the…