Transition Navigator - Return

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.

• 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.

• 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.

• Visible impact. You'll watch people reclaim their independence—and 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.