Rural Health Access Navigator

Freeman Health System; Northern (KY); Hybrid; USD 45,000 - 70,000; Full time

Job summary

Freeman Health System in Missouri is seeking an RHTP Navigator to serve as a frontline, community-based member in Hub 8 within the ToRCH Care model. The navigator connects residents to clinical, behavioral, and social services by conducting screenings, managing referrals, and addressing barriers to care.

Reporting to the Hub Program Coordinator, the navigator documents in CIE, coordinates across hospitals, FQHCs/RHCs, behavioral health providers, EMS, schools, and community organizations;

Qualifications

• This is a non-clinical role; the Navigator does not diagnose, prescribe, or provide licensed clinical treatment.

Responsibilities

• Conduct standardized screening and intake to identify clinical, behavioral, and social needs; document findings, referrals, and follow-up in CIE and other Hub systems.
• Manage closed-loop referrals and warm handoffs across Hub partners; confirm service receipt, document outcomes, and re-engage residents when referrals or services are not completed.
• Engage Medicaid members and high-need residents via calls, field visits, and partner-site follow-up; provide health education and care navigation.
• Help residents access Hub-supported services such as primary care, behavioral health, EPSDT services, chronic disease management, telehealth, and non-emergency transport.
• Identify, prioritize, and resolve barriers to care (transportation, scheduling, insurance issues, food access, digital barriers); escalate to Hub Manager when needed.
• Own assigned caseload and maintain structured follow-up until services are completed or appropriately transitioned.
• Contribute to Hub huddles, case reviews, and partner meetings; support provider coordination and improve referral pathways.
• Track and report outreach, screening, referral, and outcome data required by Hub, RCN, and RHTO; share insights with partners.
• Escalate urgent concerns to licensed staff per Hub protocols.
• Implement re-engagement strategies for hard-to-reach residents.
• Maintain community presence through outreach and events to build trust and awareness.

Job description

Freeman Health System in Missouri is seeking an RHTP Navigator to serve as a frontline, community-based member in Hub 8 within the ToRCH Care model. The navigator connects residents to clinical, behavioral, and social services by conducting screenings, managing referrals, and addressing barriers to care.

Reporting to the Hub Program Coordinator, the navigator documents in CIE, coordinates across hospitals, FQHCs/RHCs, behavioral health providers, EMS, schools, and community organizations;