Employees in this clinical position are responsible for ensuring continuity of services, with a primary responsibility for assuring that the five case management functions are carried out: assessment, planning, linking, monitoring and advocacy. This position functions as an advocate for the participant and a clinical liaison. This position has no direct supervisory responsibilities. Northern Health Care Management Transition Navigator services cover 22 counties.

Transition Navigator services are provided to assure the delivery of supports and services needed to meet an individual’s goals for living in the community after an institutionalization. Without these supports and services, the individual would otherwise remain institutionalized. Transition Navigator performances and the frequency of face-to-face and other contacts are specified in the individual’s person-centered service plan. The frequency and scope of Transition Navigation contacts must take into consideration health and welfare needs of each individual.

ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):

  • Conduct the initial and subsequent needs-based criteria evaluation and community transition assessment.
  • Support a person-centered planning process that is
    1. focused on the individual’s preferences,
    2. includes family and other allies as determined by the individual,
    3. identifies the individual’s goals, preferences and needs,
    4. provides information about options, and
    5. engages the individual in monitoring and evaluating services and supports.
  • Develop a person-centered plan of service using the person-centered planning process, including revisions to the plan at the individual’s initiation or as changes in the individual’s circumstances may warrant.
  • Refer to and coordinate with providers of home and community-based services and supports, including non-Medicaid services and informal supports. This may include helping with access to entitlements or legal representation.
  • Monitor the services and supports identified in the person-centered transition plan for achievement of the individual’s goals. Monitoring includes opportunities for the individual to evaluate the quality of services received and whether those services achieved desired outcomes. This activity includes the individual and other key sources of information as determined by the individual.
  • Provide social and emotional support to the individual and allies to facilitate life adjustments and reinforce the individual’s sources of support. This may include arranging services to meet those needs.
  • Provide advocacy in support of the individual’s access to benefits, assuring the individual’s rights as a Medicaid beneficiary, and supporting the individual’s decisions.
  • Monitor the individual after the community transition to assure a successful adjustment to community life, including assuring access to and enrollment in needed HCBS programs.
  • Maintain documentation of all efforts and activities to ensure successful support of the individual, comply with Medicaid and other relevant policies and meet quality assurance and quality improvement requirements.
  • Conduct research and outreach with AFC’s AD’S and HFA’s to inform them of the requirements and processes for becoming an appropriate provider and assess their capacity to meet contract requirements to care for participants.
  • Contact and establish good working relations with local AFC’s, ALF’s, and HFA’s including identifying those facilities with capacity, specialized services, quality and best practices as possible contract providers.
  • Request, when necessary, review of the individual program plan by the individuals interdisciplinary team.
  • Facilitate interdisciplinary team evaluation and review for assigned participants, as indicates.
  • Participate in quality Assurance case review procedures, including participant satisfactions efforts.



  • Registered Nurse licensed in the state of Michigan, or Social Worker licensed in the state of Michigan, or a non-licensed or other licensed health care profession with the following qualifications: A Bachelor’s degree in a health or human services field or community health worker certification.
  • At least three years of experience in the provision of health or social services.