RHTP Health Navigator

PFH Preferred Family Healthcare; Hannibal (MO); On-site; USD 42,000 - 56,000; Full time

Benefits offered by this job

Paid time off

Health benefits

Training and development

Career mobility

Welcoming culture

Job summary

Centerstone is seeking a Rural Health Transformation Program (RHTP) Navigator in Hannibal, MO to help residents access care and resources. You will work with local hubs to connect families to providers, track referrals, and support care plan adherence in a non-clinical role.

The role emphasizes building relationships, coordinating services across systems, and documenting outcomes using CIE and other tools. Travel within a multi-county area is required.

Qualifications

• High school diploma or equivalent with relevant community health experience
• Experience with rural communities and high-need populations
• Experience intake and needs assessments and coordinating referrals
• Ability to manage multiple cases with organized follow-up
• Experience documenting activities in digital systems (CIE/EHR)
• Valid driver's license and ability to travel across multiple counties
• Strong communication and relationship-building skills
• Bilingual skills a plus

Responsibilities

• Conduct screenings to identify clinical, behavioral health, and social service needs
• Connect residents with healthcare providers and community resources
• Initiate, manage, and track referrals through to completion
• Assist residents in overcoming barriers like transportation and housing instability
• Coordinate care across healthcare and community organizations
• Document activities and monitor referral outcomes in CIE/EHR
• Follow up with residents to encourage engagement and service completion
• Identify barriers and share insights to improve Hub operations
• Escalate urgent concerns per protocols

Skills

High school diploma

Care coordination

Resident navigation

Documentation in digital systems

Driver's license

Strong communication

Bilingual (preferred)

Tools

CIE

EHR

Job description

Job Description: RHTP Navigator Company: Centerstone Location: Hannibal, MO Shift: 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 Do

• Conduct 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 residents, families, providers, and community organizations

Preferred Qualifications

• Community Health Worker (CHW) certification or related education, training, or certification in community health, public health, social services, behavioral health, human services, or a related field
• Experience utilizing a Community Information Exchange (CIE) or other closed-loop referral platform
• Experience working within an FQHC, RHC, Critical Access Hospital, behavioral health organization, local public health agency, EMS/community paramedicine program, school-based health setting, pharmacy program, home visiting program, or community-based organization
• Experience supporting Medicaid members, dual-eligible residents, maternal‑child populations, pediatric populations, individuals with chronic disease, behavioral health populations, or individuals experiencing substance use disorder or OUD‑related support needs
• Training or experience in motivational interviewing, trauma-informed care, health coaching, benefits navigation, Mental Health First Aid, suicide prevention or other community-based behavioral health support approaches
• Experience connecting individuals to transportation services, nutrition programs, telehealth resources, preventive screenings, or home safety supports
• Relevant frontline credentials such as Behavioral Health Support Worker, Emergency Medical Technician (EMT), Certified Nursing Assistant (CNA), or Pharmacy Technician training combined with strong community-based navigation experience
• Bilingual skills or demonstrated success serving culturally and geographically diverse rural communities

What Makes You Successful

• Builds trust and meaningful relationships with residents to support ongoing engagement and care coordination
• Stays organized and effectively manages priorities across a community-based caseload
• Takes a proactive, solutions-focused approach to removing barriers and connecting residents to services
• Works collaboratively across healthcare, behavioral health, and community organizations
• Communicates clearly and professionally with diverse audiences
• Follows established workflows while adapting to the unique needs of each resident and community
• Takes ownership of referrals and follows through to completion
• Demonstrates persistence and strong follow-up skills

  Position Perks & Benefits:

  • Paid time off: full-time employees receive an attractive time off package to balance your work and personal life
  • Employee benefits package: full-time employees receive health, dental, vision, retirement, life, & more
  • Top‑notch training: initial, ongoing, comprehensive, and supportive
  • Career mobility: advancement opportunities/promoting from within
  • Welcoming, warm, supportive: a work culture & environment that promotes your well‑being, values you as human being, and encourages your health and happiness

  Brightli is on a Mission: A mission to improve client care, reduce the financial burden of community mental health centers by sharing resources, a mission to have a larger voice in advocacy to increase access to mental health and substance user care in our communities, and a mission to evolve the behavioral health industry to better meet the needs of our clients. As a behavioral and community mental health provider, we prioritize fostering a culture of belonging and connection within our workforce. We encourage applications from individuals with varied backgrounds and experiences, as we believe that a rich tapestry of perspectives strengthens our mission. If you are passionate about empowering local communities and creating an environment where everyone feels valued and supported, we invite you to join our mission‑driven organization dedicated to cultivating an authentic workplace. We are an Equal Employment Opportunity Employer.

  Preferred Family Health Care is a Smoke and Tobacco Free Workplace.

  About Brightli

  Brightli is on a mission: A mission to improve client care, reduce the financial burden of community mental health centers by sharing resources, a mission to have a larger voice in advocacy to increase access to mental health and substance use care in our communities, and a mission to evolve the behavioral health industry to better meet the needs of our clients. We are doing this by forming a new behavioral health organization under new model. Under one parent company, multiple organizations are able to collaborate, share resources and system supports, increase recruiting and retention efforts, increase access to specialized care, and meet the growing demand for behavioral and addiction recovery care. Brightli’s top‑line subsidiaries include Burrell Behavioral Health (Burrell), Preferred Family Healthcare (PFH), Southeast Missouri Behavioral Health (SEMO), Firefly, Adult and Child Health, and Places for People. While these organizations operate independently and are governed by separate board of directors, their operations and services benefit from this model. Alone, organizations may be able to navigate the current tumultuous healthcare environment, but we believe that together we can do so much more than survive. Our communities need us now more than ever, and by working together we are ready to answer their call for years to come.

  Brightli Snapshot

  200 locations 4 states 19 subsidiaries and/or affiliates 5k+ employees