Transitional Care Navigator Jobs in Michigan (NOW HIRING)

Are you a licensed Social Worker looking for a meaningful role that offers autonomy, flexibility, and the opportunity to make a real impact in your community? TANDEM365 is seeking a Social Work Navigator (MSW) to serve the Grand Rapids / Kent County area as part of our innovative, community-based care model.

Why Choose TANDEM365?

• Hybrid Work Model – A blend of remote work and in-person community visits
• Supportive Interdisciplinary Team – Collaborate with nurses, community paramedics, medical assistants, and providers
• Mission-Driven Culture – Focused on improving lives and reducing gaps in care
• Mileage Reimbursement – Starts from the moment you leave home
• Autonomous Work Environment – Manage your day while making meaningful connections with participants

Who We Are

TANDEM365 is a complex medical case management and community paramedicine program that delivers innovative, patient-centered care. We support individuals with complex medical, behavioral health, and social needs by providing in-home and community-based services designed to:

• Help participants remain safely in their homes
• Reduce unnecessary emergency department visits and hospitalizations
• Improve navigation of the healthcare and community resource systems

Our interdisciplinary model brings together medical social workers, nurses, community paramedics, and medical assistants to create a coordinated and seamless care experience.

What It’s Like to Work Here

At TANDEM365, we believe that when team members feel supported, trusted, and valued, they do their best work. We offer a self-paced orientation, strong team collaboration, and a culture that prioritizes work/life balance while allowing you to practice at the top of your license.

What You’ll Do as a Social Work Navigator

As a Social Work Navigator, you will provide community-based social work services to participants with complex medical and psychosocial needs. You will conduct in-home and phone assessments, develop person-centered care plans, and work collaboratively with the care team to support participants across the continuum of care.

• Conduct in-home and phone-based psychosocial assessments to inform individualized plans of care
• Identify and address social determinants of health through targeted interventions
• Coordinate and collaborate with mental health providers, medical providers, and community agencies
• Provide resource connection and navigation, including housing, financial, food, and social supports
• Facilitate advance care planning conversations and support goal-aligned care
• Support appropriate transitions to hospice when indicated
• Empower participants through self-management education and goal setting
• Conduct challenging, goal-focused conversations with participants and families
• Partner with the interdisciplinary team to prevent unnecessary hospital utilization
• Maintain timely and accurate documentation using electronic systems

What You’ll Need to Succeed

• Flexibility, resilience, and adaptability in a fast-paced, community-based environment

• Ability to work independently and autonomously while staying connected to a team
• Strong organizational and prioritization skills
• Comfort navigating multiple technologies and electronic documentation systems
• Excellent communication skills, including comfort with complex and sensitive conversations
• A collaborative, team-oriented mindset

Education & Experience Requirements

• Master of Social Work (MSW) preferred/ Experienced BSW considered
• Active Social Work licensure in the State of Michigan
• Minimum of 3 years of social work experience
• Experience in community-based, healthcare, post-acute, or older adult care strongly preferred
• Experience supporting individuals with behavioral health conditions and complex chronic medical needs preferred
• Knowledge of community resources and strong care coordination skills
• Experience with Advance Care Planning, Medicare/Medicaid, or SHIP is highly valued

Ready to Make an Impact? Apply Today!

Join TANDEM365 and be part of a team that is redefining community-based care and improving the lives of individuals throughout the Grand Rapids area.

Apply today to learn more about this exciting opportunity.