Transition Navigator - Help People Return Home

Make a Real Difference Every Day

Imagine helping someone leave a nursing facility and walk back into a home of their ownkeys 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.

What You'll Do

• Build the plan together. Meet individuals face-to-face, complete Community Transition Assessments, and co-create Person-Centered Service Plans alongside participants, families, and guardiansaddressing 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 (5060% of monthly workload), and submit billing and claims by the 10th of each month.

What You Bring

• 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

Why You'll Love This Work

• Visible impact. You'll watch people reclaim their independenceand you made it possible.
• Variety. No two days look alike: planning, fieldwork, hands-on move days, and community partnership.
• Purpose-driven team. Join The Information Center, an organization with deep roots in Michigan's long-term services and supports.

The Information Center is an equal opportunity employer. We welcome applicants of all backgrounds.

Ready to help people get home? Apply today.