What are the responsibilities and job description for the Transition Navigator - Help People Return Home position at The Information Center, Inc.?
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.
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 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 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 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.
Opus 4.8 High
Salary : $48