Transition Navigator - Help People Return Home

The Information Center, Inc. • Taylor, MI

11d • Hybrid

About The Position

Make a Real Difference Every Day Imagine helping someone leave a nursing facility and walk back into a home of their own—keys in hand, furniture arranged, support in place. That's the heart of this role. As a Transition Navigator, you'll guide Medicaid-eligible individuals through every step of moving from a nursing facility back into the community, using person-centered planning to turn "I wish I could go home" into "I'm home." If you're a social worker or nurse who wants your work to mean something tangible, this is it.

Requirements

• A current Michigan license as an LBSW, LMSW, or RN
• Experience with person-centered planning, long-term care, and HCBS services
• A talent for building relationships and solving problems creatively
• Strong attention to detail and clear communication, written and verbal
• Comfort with Word, Excel, and Outlook
• A valid Michigan driver's license, auto insurance, and reliable transportation
• Ability to lift/carry 25 lbs. and stand for extended periods on move-in days

Responsibilities

• Build the plan together. Meet individuals face-to-face, complete Community Transition Assessments, and co-create Person-Centered Service Plans alongside participants, families, and guardians—addressing real needs, costs, and barriers.
• Make the move happen. Shop for household goods, prepare the living space, and be there on move-in day to help set everything up and make sure it feels like home.
• Open doors to housing. Assist with housing searches, applications, and getting the new place move-in ready.
• Connect people to support. Link participants to home and community-based services (HCBS), monitor how things are going, and adjust the plan as life changes.
• Be the steady point of contact. Partner with nursing facility staff, MI Choice waiver agencies, Area Agencies on Aging, Centers for Independent Living, and HIDE SNPs to keep care seamless.
• Follow through with care. Conduct post-transition check-ins within 30 days, report critical incidents to MDHHS, manage prior authorizations through CHAMPS, and keep documentation accurate and confidential.
• Handle the administrative side. Track referrals in the NFT Portal in COMPASS, maintain billable units (50–60% of monthly workload), and submit billing and claims by the 10th of each month.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed