oracle
RHTP Program Navigator
MOSAIC
Maryville, USA
Full-time
Mid
Onsite
Discovered 1 weeks ago
Communication
Key Skills for This Role
Communication
Full Job Posting
Qualifications
- Skills and Abilities
- Essential Technical/Motor Skills
- Ability to manage multiple active cases and maintain organized follow-up across residents and partners
- Ability to accurately document and track activities using digital systems (e.g., CIE, EHR, or case management tools)
- Manages time and priorities effectively across a field-based caseload, maintaining consistent follow-up and coordination
- Works effectively across multiple organizations and disciplines to coordinate services and support continuity of care
- Takes ownership of tasks and ensures referrals and services are completed
- Interpersonal Skills
- Strong verbal and written communication skills and the ability to build trust with patients, families, providers, and community organizations
- Builds and maintains trust with residents to support ongoing engagement and follow-through on services
- Communicates clearly and effectively with residents, families, and professionals across settings
- Demonstrates persistence in engaging residents and navigating barriers, including repeated outreach when needed
- Essential Physical Requirements
- Essential Mental Abilities
- Practical problem-solver who can remove barriers to care using available community and provider resources
- Works independently in community-based, field settings, including travel between homes, clinics, and partner sites
- Follows standardized workflows and documentation requirements while adapting approach to individual and community needs
- Essential Sensory Requirements
- Exposure to Hazards
- Other Skills and Abilities
Responsibilities
- Conduct standardized screening and intake to identify clinical, behavioral, and social needs; document findings, referrals, and follow-up in the Community Information Exchange (CIE) and other Hub-approved systems
- Manage closed-loop referrals and warm handoffs across Hub partners, including hospitals, FQHCs/RHCs, behavioral health providers, pharmacies, EMS/community paramedicine, local public health agencies, schools, and community-based organizations; confirm service receipt, document outcomes, and re-engage residents when referrals or services are not completed
- 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 Hub-supported services such as primary care, behavioral health, women’s health and prenatal care, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, chronic disease management, healthy homes services, home visiting, pharmacy-based services, telehealth, and non-emergency medical transportation
- Identify, prioritize, and resolve barriers to care, including appointment scheduling, transportation, medication access, benefits or insurance issues, food and nutrition supports, and digital-access barriers; escalate recurring or complex barriers requiring Hub Program Manager review or broader workflow changes
- Own an assigned caseload and maintain structured follow-up until services are completed, needs are resolved, or care is appropriately transitioned; document outreach attempts, referral status, service completion, and barriers requiring continued action or escalation
- Actively contribute to Hub huddles, case reviews, and partner meetings; support provider coordination and contribute frontline insights to improve referral pathways, workflows, and local program design
- Track and report outreach, screening, referral, and outcome data required by the Hub, RCN, and RHTO; share qualitative insights and best practices with Hub and regional partners
- Escalate urgent clinical, behavioral health, or safety concerns to licensed staff or supervisors according to Hub protocols
- Implement re-engagement strategies, including multi-channel outreach and coordination with partner organizations, for residents who are difficult to reach or who do not complete referred services
- Maintain a visible presence in the community through outreach activities, partner site engagement, and local events to build awareness of Hub services, strengthen referral relationships, and support resident trust
- Other duties as assigned
- Education
- H.S. Diploma - High school diploma or equivalent – Required
- Associate’s Degree – Community Health, Public Health, Social Services, Behavioral Health, Human Services, or a related field - Preferred
- Work Experience
- 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- Preferred
- 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, among others – Required
- Experience conducting resident, client, or patient intake and needs screening and following through on referrals to completion – Preferred
- Experience using a Community Information Exchange (CIE) or other closed-loop referral platform to manage closed-loop referrals, track service completion, and document outcomes – Preferred
- Experience in one or more settings central to the Hub model, such as an FQHC, RHC, Critical Access Hospital, behavioral health agency, local public health agency, EMS/community paramedicine program, school-based health setting, pharmacy program, home visiting program, or community-based organization – Preferred
- Experience serving Medicaid members, dual-eligible residents, maternal/child populations, pediatric populations, individuals with chronic disease, behavioral health populations, or people with substance use disorder or OUD-related support needs – Preferred
- Training or demonstrated experience in motivational interviewing, trauma-informed care, health coaching, benefits navigation, Mental Health First Aid, suicide prevention training, or other community-based behavioral health support approaches – Preferred
- Experience supporting access to services such as transportation, food/nutrition programs, home safety, preventive screenings, or telehealth – Preferred
- Relevant frontline credentials in addition to CHW experience may be helpful, such as Behavioral Health Support Worker, Emergency Medical Technician, Certified Nursing Assistant, or Pharmacy Technician training, when paired with strong community-based navigation experience – Preferred
- Bilingual skills or demonstrated effectiveness serving culturally and geographically diverse rural communities - Preferred
- Licenses and Certifications
- Driver's License - Valid - Required Upon Hire
- Community Health Worker (CHW) training/certification or related training - Preferred
About MOSAIC
Hospitals & Health Systems4000 employeesFounded 2012
Nonprofit healthcare system providing patient-centered care in the Midwest.
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