Stroke Team Navigator Social Work - Patient Care Coordination - Full Time/Days - Req#2097474187

Job Objective:

The Stroke Navigator, Social Work serves as an advanced, independent clinical professional responsible for coordinating psychosocial services and care navigation across the stroke continuum of care. This position functions autonomously and exercises significant professional judgment in psychosocial assessment, discharge planning, stroke program compliance, post-acute coordination, and collaboration with interdisciplinary and external partners. The Stroke Navigator contributes to stroke program performance improvement, regulatory readiness, and ensures comprehensive, patient-centered care for individuals and families impacted by acute cerebrovascular events.

Duties and Responsibilities:

A. Stroke Social Work & Psychosocial Assessment

1. Respond to acute stroke admissions and complete timely psychosocial assessments aligned with stroke pathways.

2. Provide crisis intervention, adjustment counseling, emotional support, and education related to new neurological deficits and functional changes.

3. Identify SDOH risks including caregiver availability, housing stability, transportation barriers, financial strain, health literacy, and access to follow-up care.

4. Support patients and families with decision-making related to level of care, goals of care, and post-acute options as appropriate.

• Care Coordination & Discharge Planning

1. Develop complex discharge plans tailored to stroke severity, functional deficits, cognitive status, and rehabilitation needs.

2. Coordinate transitions of care to inpatient rehabilitation, skilled nursing facilities, home health, outpatient therapy, and behavioral health services.

3. Address barriers to discharge including placement delays, insurance authorization challenges, caregiver limitations, and equipment needs.

4. Participate in stroke rounds, interdisciplinary huddles, and multidisciplinary case conferences to support timely, safe discharges.

C. Stroke Program Support & Compliance

1. Ensure psychosocial documentation supports Joint Commission Stroke Certification, CMS, Title 22, and hospital stroke program requirements.

2. Collaborate with Stroke Program leadership to support stroke metrics, core measures, and certification readiness.

3. Track psychosocial, discharge, and SDOH-related indicators relevant to stroke outcomes and readmission risk.

4. Provide education to staff on stroke-related psychosocial considerations, caregiver burden, community resources, and post-stroke adjustment.

• Post-Discharge Follow-Up

1. Conduct follow-up for high-risk stroke patients to assess adherence to follow-up appointments, medications, therapy, and safety plans.

2. Identify and address gaps in care related to transportation, outpatient services, insurance coverage, or caregiver support.

3. Support coordination with primary care, neurology, rehabilitation providers, and community agencies to reduce readmissions.

• Data, Reporting & Performance Improvement

1. Analyze trends related to discharge delays, placement barriers, readmissions, and psychosocial risk factors impacting stroke outcomes.

2. Prepare and present data summaries, dashboards, and outcome reports to Stroke Medical Director, Stroke Program Manager, and hospital leadership.

3. Identify opportunities for system improvement related to care transitions, rehabilitation access, and social drivers impacting recovery.

4. Support survey readiness and accreditation activities through audits, case reviews, and timely reporting.

Non-Essential Duties:

• Assist with other duties as assigned within scope of licensure and competency.
• Participate in hospital committees, workgroups, and training as requested.
• Support disaster response or surge capacity needs when appropriate.
• Provide coverage for other social work functions during absences or high-volume periods.

Knowledge, Skills and Abilities:

Knowledge

• Stroke continuum of care, including acute, post-acute, and community-based recovery pathways.

• Joint Commission Stroke Certification standards, CMS core measures, and Title 22 requirements.

• Psychosocial and functional impacts of stroke, including cognitive, emotional, and caregiver considerations.

• Community, county, and state resources including rehabilitation services, insurance programs, disability benefits, and behavioral health supports.

• Medical terminology and interdisciplinary stroke workflows.

• California mandated reporting requirements

Skills

• Advanced psychosocial assessment and clinical interviewing skills.

• Strong care coordination and discharge planning capabilities for complex neurological patients.

• Effective communication with patients, families, physicians, nursing, rehabilitation, and leadership.

• Proficient documentation for regulatory review, audits, and stroke program reporting.

• Ability to manage competing priorities while supporting time-sensitive stroke throughput goals.

Abilities

• Work independently within a fast-paced acute care stroke environment.

• Exercise sound judgment in complex clinical and discharge planning situations.

• Build rapport with patients and families adjusting to sudden, life-altering diagnoses.

• Navigate healthcare systems and advocate for safe, timely transitions of care.

• Collaborate effectively with neurology, ED, nursing, PT/OT/ST, case management, and hospital leadership.

• Prioritize tasks and manage time efficiently while supporting program performance goals.

AVMC Values: All AVMC employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.

Education and Experience:

Education

• Master’s degree in social work required

Experience

• 3 years hospital social work experience required

• ED or Stroke experience preferred.

Required Licensure and/or Certifications:

• MSW or LCSW required

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Attendance and Punctuality Policy.

• Ability to adhere with AVMC Leaves of Absence Policy.

• Ability to adhere with AVMC Paid Time Off (PTO) Policy.

• Ability to adhere to the department dress code.

• Ability to organize work and establish priorities.

• Ability to expand on own initiative in performance of duties.

• Skill and ability to follow the telephone etiquette/standards.

• Ability to function effectively under pressure and meet time parameters.

• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.

• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.

• Ability to maintain the confidentiality of patient, hospital and department information.

• Ability to adhere to safety rules and regulations.

• Safely and effectively uses all equipment necessary to carry out duties.

• Ability to interpret and function under hospital and department policies and procedures.

• Conforms with required and appropriate accreditation and regulatory requirements.

• Conforms with and supports hospital quality assurance and improvement guidelines.

• Ability to participate effectively in department and hospital staff education.

• Display a willingness to work as a team player.

• Ability to give and support the highest level of patient/customer satisfaction at all times.

• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.

• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.

• Ability to follow the Code of Conduct.

Physical Requirements and Working Conditions:

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

Education and Experience:

Education

• Master’s degree in social work required

Experience

• 3 years hospital social work experience required

• ED or Stroke experience preferred.

Required Licensure and/or Certifications:

• MSW or LCSW required