Lead Rural Navigator

providers, pharmacies, emergency medical services (EMS), local public health agencies (LPHA), and community-based organizations to coordinate clinical, behavioral, and social care for rural residents. Reporting directly to the Hub Program Director, the Lead Navigator is responsible for ensuring rural residents successfully connect to and complete needed clinical, behavioral, and social services by conducting screenings, initiating and managing referrals, and addressing barriers to care. While a non-clinical role, the Lead Navigator builds relationships with residents, supports engagement and follow-through, and escalates urgent medical, behavioral health, or safety concerns per Hub protocols.

Duties & Responsibilities

(Most important duties first)

• Screening & Referral: Conduct standardized intake screenings of rural residents to identify clinical, behavioral, and social care needs; initiate and manage closed-loop referrals across Hub partners via the Community Information Exchange (CIE) and other digital systems. Emergencies are escalated immediately per Hub policy/protocols.
• Resident Engagement & Care Navigation: Engage Medicaid beneficiaries, dually eligible residents, and high-need individuals through phone calls, field visits, and partner-site follow-ups to assist with appointment scheduling, care plan adherence, and service navigation.
• Barrier Mitigation: Identify/resolve non-clinical barriers to care, including non-emergency medical transportation, benefit/insurance enrollment, medication access, and digital access barriers.
• Partner Coordination & Handoffs: Lead warm handoffs and actively facilitate bidirectional coordination between residents and local partners. Ensure both the resident and receiving provider entities-including local hospitals, FQHCs, RHCs, behavioral health agencies, EMS, LPHAs, pharmacies, and CBOs-have the necessary context and follow-through to maintain continuity of care.
• Caseload & Documentation: While this is a non-clinical role, maintain an active caseload, tracking outreach attempts, referral statuses, and outcomes in approved digital systems until services are verified as complete or appropriately transitioned.
• Community Presence & Outreach: Organize and participate in recurring joint outreach initiatives with Hub partners, co-representing community health programs at local events to model unified partner collaboration and build public trust and program awareness.
• Data Collection & Outcome Tracking: Track, aggregate, and report frontline clinical, behavioral, and social care outcomes to evaluate program impact across the Hub's population (e.g., tracking ED visit reduction following crisis intervention, prenatal visit adherence, and social care completion rates). Assist Program Director in compiling dashboard metrics, KPIs, and outcome reports for the Rural Health Transformation Office (RHTO) and state partners.
• Governance & Board Operational Support: In coordination with the Program Director, assist with preparing materials for Hub Board meetings, including agenda distribution, metric dashboards, and meeting summaries. Attend Leadership Board meetings to record actions and votes, and support post-meeting follow-up communications, documentation, and proposal preparations for RHTO and Hub partners.

Job Responsibilities

• Under the direction of leadership, supports implementation, workflow execution, and reporting activities of the State-funded ToRCH Care program for Region 16.
• Directly delivers community navigation, social care referral management, barrier mitigation, and resident engagement services across Adair, Macon, Knox, and Shelby counties.

Requirements

Education & Experience

Minimum Educational Requirement: Four-year college degree in relevant field is preferred (e.g., BSN, human services, public health, social work, or related field) or equivalent clinical/community care management experience. Consideration given to candidates with nursing credentials such as RN or an associate degree with extensive healthcare navigation experience.

Specific Knowledge Areas Required:

• Knowledge of local community resources, social service systems, and healthcare providers in the assigned multi-county region.
• Basic understanding of social determinants of health (SDOH), public benefits (e.g., Medicaid), and care coordination concepts.
• Familiarity with data entry, privacy standards (HIPAA), and digital communication tools.

Experience Requirements

Amount Needed Prior to Placement: Two to three years.

Specific Experience Needed:

• Experience in community outreach, patient navigation, social services, care coordination, public health, or customer service in a healthcare or CBO setting.
• Experience in conducting resident, client, or patient intake and needs screening and following through on referrals to completion.
• Demonstrated experience working directly with rural or high-need populations facing social or economic barriers.
• Experience using digital systems (i.e., CIE, EHR, or case management software) for documentation and tracking.
• Preferred: Certified Community Health Worker (CHW), or experience in Motivational Interviewing, Trauma-Informed Care, or Mental Health First Aid.
• Preferred: Experience in one or more settings such as an FQHC, RHC, Critical Access Hospital, behavioral health agency, LPHA, EMS, school-based health setting, pharmacy, home visiting program, or related CBO.

Skill Requirements

• Ability to collect, organize, and analyze program performance metrics, social determinant data, and healthcare utilization outcomes for reporting and presentation purposes.
• Strong attention to detail, ability to track multiple deadlines, and organize projects, clients, and partners.
• Excellent interpersonal, active listening, and relationship-building skills to establish trust with diverse residents.
• Ability to manage multiple active cases and maintain organized follow-up across residents and partners.
• Strong verbal and written communication skills; bilingual skills or demonstrated effectiveness serving culturally and geographically diverse rural communities is a plus.
• Practical problem-solving and time management skills to manage a field-based caseload independently.
• Technical: Basic computer literacy (Microsoft Office, Google Workspace, Web-based databases).
• Valid driver's license and ability to travel within a four-county Hub service area.

Personal Characteristics or Traits

• Empathy, compassion, and cultural humility when serving vulnerable populations.
• Adaptability and persistence in navigating complex community systems and overcoming barriers.
• High level of personal integrity, accountability, and respect for client confidentiality.
• Service minded with a commitment to supporting healthcare access improvements across rural northeast Missouri.
• Self-motivated with the ability to work independently in field environments.
• Persistent in engaging rural residents and navigating barriers, including repeated outreach, when needed.
• Effective at managing time/priorities across a field-based caseload, maintaining consistent follow-up and coordination.
• Detail oriented, punctual, and reliable with excellent follow-through on operational tasks and administrative requests.
• Adept at following standardized workflows and documentation requirements while adapting approach to individual and community needs.

Other Information

• Travel Requirements: Frequent travel throughout multi-county Hub geography; daily local travel expected.
• Non-Clinical Nature: This is a non-clinical role. The Lead Navigator does not diagnose, prescribe, or provide licensed clinical treatment.
• Background Checks: Successful completion of background checks is required prior to employment.

Mandatory Federal Grant Attribution (State Requirement): "The Rural Health Transformation Program information provided by the Missouri Department of Social Services is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $216,276,817.66, with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS, or the U.S. Government."

ATSU offers a comprehensive benefits package including medical, dental, and vision coverages, among more. If eligible, employee-elected benefits would begin the first of the month following hire date. For more information, please visit: atsu.edu/employment/benefits.

A.T. Still University (ATSU) does not discriminate on the basis of race, color, religion, ethnicity, national origin, sex (including pregnancy), sexual orientation, age, disability, or veteran status in admission or access to, or treatment or employment in its programs and activities.

To apply, visit https://recruiting.paylocity.com/Recruiting/Jobs/Details/4471465