Program Navigator

Jobtailor; Maryville (MO); On-site; USD 42,000 - 64,000; Full time

Job summary

Jobtailor is seeking a Field Care Navigator to support rural communities with care coordination and case management. You will conduct intake, assess needs, document referrals, and manage closed-loop processes across healthcare and social service partners.

You will engage high-need residents, provide health navigation, and help them access primary and behavioral health services, EPSDT, and transportation solutions. Strong documentation and collaboration are essential.

Qualifications

• High school diploma or equivalent.
• Experience in community health work, care coordination, case management, patient navigation, Medicaid care management, behavioral health support, public health outreach, social services, or related field.
• Experience serving rural communities and/or high-need populations with barriers like transportation, food insecurity, housing instability, low digital access, limited provider access, or fragmented behavioral health services.
• Experience with resident intake and needs screening and following referrals to completion.
• Valid driver’s license and ability to travel between facilities and off-site locations.
• Ability to manage multiple active cases and maintain organized follow-up.
• Associate’s degree in a related field preferred.
• Experience using a Community Information Exchange or closed-loop referral platform preferred.
• Community Health Worker training/certification or related training preferred.
• Bilingual skills preferred.

Responsibilities

• Conduct standardized screening and intake to identify clinical, behavioral, and social needs.
• Document findings, referrals, and follow-up in the Community Information Exchange and other hub systems.
• Manage closed-loop referrals and warm handoffs across agencies and providers.
• Confirm service receipt, document outcomes, and re-engage residents when referrals are incomplete.
• Engage Medicaid members and high-need residents through calls, visits, and outreach.
• Provide health education, care navigation, and reinforce care plans.
• Help residents access primary care, behavioral health, prenatal care, EPSDT, and other services.
• Identify and resolve barriers to appointments, transportation, medications, benefits, nutrition, and digital access.
• Manage a caseload and maintain follow-up until needs are resolved.
• Participate in hub huddles, case reviews, and partner meetings.
• Track and report outreach, screening, referrals, and outcomes.

Skills

Community Health Work

Care Coordination

Case Management

Behavioral Health Support

Medicaid Care Management

Education

Associate’s degree in a related field

Community Health Worker Certification

Tools

Community Information Exchange

Electronic Health Record

Case Management Tools

Job description

Responsibilities

• Conduct standardized screening and intake to identify clinical, behavioral, and social needs
• Document findings, referrals, and follow-up in the Community Information Exchange and other Hub-approved systems
• Manage closed-loop referrals and warm handoffs across hospitals, FQHCs, RHCs, behavioral health providers, pharmacies, EMS, public health agencies, schools, and community organizations
• Confirm service receipt, document outcomes, and re-engage residents when referrals are incomplete
• 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 primary care, behavioral health, prenatal care, EPSDT services, chronic disease management, healthy homes services, home visiting, pharmacy services, telehealth, and non-emergency medical transportation
• Identify, prioritize, and resolve barriers involving appointments, transportation, medication access, benefits, food and nutrition, and digital access
• Manage an assigned caseload and maintain structured follow-up until services are completed or needs are resolved
• Participate in Hub huddles, case reviews, and partner meetings
• Track and report outreach, screening, referral, and outcome data
• Escalate urgent clinical, behavioral health, or safety concerns according to Hub protocols
• Implement multi-channel re-engagement strategies
• Maintain a visible presence through community outreach, partner engagement, and local events
• Report to the Hub Program Manager

Requirements

• High school diploma or equivalent — Required
• 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
• Demonstrated 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 — Required
• Experience conducting resident, client, or patient intake and needs screening and following through on referrals to completion — Required
• Valid driver's license required upon hire
• Must be able to travel between various system facilities and off-site locations as needed
• Ability to manage multiple active cases and maintain organized follow-up
• Ability to accurately document and track activities using digital systems such as CIE, EHR, or case management tools
• Ability to work effectively across multiple organizations and disciplines
• Strong verbal and written communication skills
• Ability to build trust with residents, families, providers, and community organizations
• Practical problem-solving skills for removing barriers to care
• Ability to work independently in community-based field settings
• Ability to follow standardized workflows and documentation requirements
• Associate’s degree in a related field — Preferred
• Experience using a Community Information Exchange or closed-loop referral platform — Preferred
• Community Health Worker training/certification or related training — Preferred
• Bilingual skills — Preferred

Core Competencies

Demonstrates expertise in community health work, care coordination, and case management, with a focus on engaging high-need populations and addressing barriers to care. Proficient in utilizing digital systems for documentation and tracking, while effectively collaborating across multiple organizations.

Highest-signal resume keywords

• Community Health Work
• Care Coordination
• Case Management
• Behavioral Health Support
• Medicaid Care Management

ATS Optimization Keywords

Hard Skills

• Patient Navigation
• Needs Screening
• Referral Management
• Documentation
• Data Tracking

Soft Skills

• Verbal Communication
• Written Communication
• Problem-Solving
• Trust Building
• Organizational Skills

Certifications & Qualifications

• Community Health Worker Certification
• Bilingual Skills

Industry Keywords

• Public Health Outreach
• Social Services
• High-Need Populations
• Transportation Barriers
• Food Insecurity

Tools & Technologies

• Community Information Exchange
• Electronic Health Record
• Case Management Tools