Northern Lakes Community Mental Health Authority (NLCMHA) recognizes the value of and employs people with lived experience and believes strongly in Recovery and a Culture of Gentleness. To this end, this position requires a commitment to creating and maintaining a culture that “Expects Recovery” and “Encourages Gentleness.”

Employees in this clinical position are responsible for ensuring continuity of services, with a primary responsibility for assuring that transactional case management functions of which individuals are in need are carried out: assessment, planning, linking, monitoring and advocacy. This position functions as an advocate for the participant and a clinical liaison service broker. The employee reports to the Program Director as assigned. This position has no direct supervisory responsibilities. Must strongly believe in recovery and have a commitment to creating and maintaining a culture that expects recovery.


ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):

  • Must be an effective communicator both in-person and in-writing, and can develop positive working relationships with community partners/stakeholders. Ability to work with nursing facility staff and residents, their allies, and facility.
  • Provide education and training regarding the scope of Nursing Facility Transfer Service (NFT), program offerings including supports options available in the community such as MI Choice, Disability Network, PACE, housing and/or residential services. Additionally, provide education, and support to those interested in receiving NFT services, their informal supports and facility staff.
  • Must provide an initial assessment of interested individuals. Monitor treatment plan follow-up, services to participant and overall conditions. Work with the providers to make necessary improvements. Follow-up problem areas as appropriate.
  • The Clinical Navigator will connect individuals with home and community-based programs or services of their choice before transition and will assure a smooth transition to the community, including residential services option and work with DHHS to identify Adult Foster Care (AFC) and Homes for the Aged (HFAs) that provide good care. Safely transition clients from NF to community placement. Must timely and accurately track NFT referrals
  • Input the appropriate documentation/ information into the EMR system. Contact and establish good working relationships with local Nursing Facilities, AFCs and HFAs including identifying those facilities with capacity, specialized services, quality and best practices as possible contract providers. Track and report information required by MDHHS, data on AFC and HFAs for provision of residential services option. Maintain a database of low-income housing, grants, MSHDA vouchers, waitlists, agencies that provide housing assistance.
  • Coordinate Person-Centered Planning. In doing so, attend to the total spectrum of the individual’s needs, including but not necessarily limited to: housing, family relationship, social activities, education, finance, employment, health, recreation, mobility, protective services and records. Develop a person-centered service plan for each participant approved by MDHHS in the NFT Portal, which also provides a foundation for thorough planning of meeting medical needs as well as environmental and psycho-social concerns.
  • Intervene when necessary to assure implementation of the plan. Report all critical incidents that occur with NFT participants to MDHHS using the critical incident database
  • Facilitate interdisciplinary team evaluation and review for assigned participants, as indicated.
  • Evaluate, facilitate and monitor services and participants’ progress in relationship to established goals and objectives and document as appropriate.
  • Participate in Quality Assurance case review procedures, including participant satisfaction.
  • Must complete NFLOC assessments.
  • Other duties as assigned.




Bachelor’s Degree in Social Work, or licensed RN from an accredited university. Must be a qualified Case Manager/Supports Coordinator.

One (1) year of experience in long term care services is preferred.

One (1) year of experience in working with nursing facilities preferred. Knowing of community available community resources.



Must have licensure with the State of Michigan as a Licensed Bachelors Social Worker or Limited Licensed Bachelors Social Worker or Licensed Registered Nurse. Must maintain licensure.