Rural Health Transformation Navigator

Graceworks Lutheran Services; Neosho (MO); On-site; USD 42,000 - 52,000; Full time

Job summary

ACCESS Family Care in Southwest Missouri is seeking an RHTP Hub 8 Navigator to serve as a frontline resource and care coordination partner for residents across the Hub service area. You will screen, refer, and support families to access clinical, behavioral health, and social services.

This non-clinical role focuses on outreach, advocacy, and ensuring timely service completion, with frequent travel throughout Barton, Jasper, Newton, and McDonald Counties, and collaboration with hospitals,

Qualifications

• Minimum qualifications include experience in community health work, care coordination, case management, patient navigation or related fields.
• Experience working with rural or underserved populations and using electronic documentation systems is preferred.
• Strong organizational, communication, and problem-solving skills required.

Responsibilities

• Coordinate and manage referrals to clinical, behavioral health, and social services with a closed-loop system.
• Screen and assess healthcare, behavioral health, and social needs using standardized intake tools.
• Facilitate warm handoffs and follow up until services are completed.
• Engage in community outreach and build partnerships to improve resource access.
• Track outreach, referrals, and outcomes and report data to Hub leadership.

Skills

Community Health Work

Care Coordination

Case Management

Patient Navigation

Medicaid Care Management

Behavioral Health Support

Public Health Outreach

Social Services

Related Human Services Fields

Education

Associate's or Bachelor's degree in Public Health, Social Services, Human Services, Behavioral Health, or related fields

Job description

Location: Hub 8 (Barton, Jasper, Newton, and McDonald Counties, Missouri)

Position Type: Full-Time

Schedule: Monday-Friday, 8:00 AM-5:00 PM (hours may vary; occasional evenings and weekends required for outreach activities)

Travel: Frequent travel throughout Barton, Jasper, Newton, and McDonald Counties

Join Our Team as an RHTP Hub 8 Navigator

ACCESS Family Care is seeking a dedicated, community-focused professional to serve as an RHTP Hub 8 Navigator. This position plays a vital role in Missouri's Transformation of Rural Community Health Care (ToRCH Care) Model, helping rural residents access healthcare, behavioral health services, and community resources that improve overall health outcomes.

As a Navigator, you will work directly with patients, families, healthcare providers, and community partners to identify needs, coordinate services, and remove barriers to care. This is an excellent opportunity for individuals passionate about making a meaningful impact in the communities they serve.

About the Role

The RHTP Hub 8 Navigator serves as a frontline community resource and care coordination partner for residents across Southwest Missouri. Working closely with healthcare organizations, community agencies, and social service providers, the Navigator helps individuals successfully connect to clinical, behavioral, and social support services.

The Navigator conducts screenings, coordinates referrals, follows up on service completion, and assists residents in overcoming barriers such as transportation, food insecurity, housing instability, insurance challenges, and limited access to healthcare services.

This is a non-clinical position focused on advocacy, navigation, outreach, and care coordination.

Care Coordination & Navigation

• Conduct standardized screenings and intake assessments to identify healthcare, behavioral health, and social service needs.
• Document screenings, referrals, outcomes, and follow-up activities in the Community Information Exchange (CIE) and other approved systems.
• Coordinate and manage closed-loop referrals to ensure residents successfully access needed services.
• Facilitate warm handoffs between patients and healthcare, behavioral health, and community service providers.
• Maintain an assigned caseload and provide ongoing follow-up until services are completed or needs are resolved.

Community Outreach & Engagement

• Engage residents through phone calls, community outreach events, partner-site visits, and field-based outreach.
• Build trusting relationships with patients, families, and community partners.
• Maintain a visible presence throughout the Hub service area to increase awareness of available resources.
• Assist residents with healthcare navigation, health education, and care plan adherence.

Barrier Resolution

• Help residents overcome barriers involving:
  • Transportation
  • Insurance and Medicaid issues
  • Food and nutrition needs
  • Medication access
  • Scheduling and appointment coordination
  • Digital access and telehealth utilization
• Escalate complex issues and recurring service gaps to Hub leadership.
• Participate in Hub meetings, case reviews, and partner collaboration activities.
• Work closely with hospitals, FQHCs, rural health clinics, behavioral health providers, EMS teams, public health agencies, schools, pharmacies, and community-based organizations.
• Track and report outreach, referral, and outcome data.
• Share frontline insights to improve local programs and service delivery.

Safety & Compliance

• Escalate urgent medical, behavioral health, or safety concerns according to established protocols.
• Maintain confidentiality and compliance with organizational policies and applicable regulations.
• Perform other duties as assigned.

Minimum Qualifications

• High School Diploma or equivalent.
• Experience in one or more of the following areas:
  • Community Health Work
  • Care Coordination
  • Case Management
  • Patient Navigation
  • Medicaid Care Management
  • Behavioral Health Support
  • Public Health Outreach
  • Social Services
  • Related Human Services Fields
• Experience working with rural or underserved populations.
• Ability to conduct screenings, manage referrals, and provide follow-up services.
• Strong organizational and time-management skills.
• Proficiency using electronic systems for documentation and reporting.
• Excellent verbal and written communication skills.
• Valid driver's license and reliable transportation for frequent travel throughout the Hub service area.

Preferred Qualifications

• Community Health Worker (CHW) Certification.
• Associate's or Bachelor's degree in Public Health, Social Services, Human Services, Behavioral Health, or related fields.
• Experience using Community Information Exchange (CIE) or closed-loop referral systems.
• Background in healthcare, behavioral health, public health, EMS, pharmacy, education, or community-based organizations.
• Experience serving Medicaid populations, maternal-child health populations, individuals with chronic disease, behavioral health needs, or substance use disorders.
• Training in:
  • Motivational Interviewing
  • Trauma-Informed Care
  • Health Coaching
  • Mental Health First Aid
  • Benefits Navigation
  • Suicide Prevention
• Bilingual skills are a plus.

What We're Looking For

Successful candidates will demonstrate:

• Compassion and empathy for diverse populations.
• Strong relationship-building and communication skills.
• Ability to work independently in community-based settings.
• Excellent problem-solving capabilities.
• Persistence and follow-through in helping residents access services.
• Ability to manage multiple priorities while maintaining accurate documentation.
• Collaboration and teamwork across multiple organizations and disciplines.

Why Join Access Family Care?

At ACCESS Family Care, we are committed to improving the health and well-being of our communities. As an RHTP Hub 8 Navigator, you will have the opportunity to make a direct impact on the lives of rural residents by connecting them to critical healthcare and community resources while helping strengthen the future of healthcare delivery across Southwest Missouri.