A.T. Still University's Kirksville College of Osteopathic Medicine (ATSU-KCOM) is seeking a full time, exempt Lead Rural Navigator on the Kirksville, Missouri campus. The Lead Rural Navigator serves as a frontline, community-based care coordinator for the four-county, Region 16 Hub within Missouri’s Transformation of Rural Community Health Care (ToRCH Care) model. Local Hubs will bring together hospitals, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), behavioral health 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.
