Medical Social Worker - NBGW Addiction Medicine (Full Time, Days)

About the role

NorthBay Health is seeking a Medical Social Worker to support inpatient hospital units and broader care coordination efforts in Fairfield, CA. This role improves patient outcomes through clinical intervention, education, and continuity of care across inpatient and outpatient settings, and helps identify patients at risk for readmission while ensuring seamless transitions across the continuum of care.

Responsibilities

• Provide direct clinical social work services, counseling, discharge planning, and case management to hospital patients and families, including biopsychosocial assessment and documentation of emotional, psychological, social, financial, environmental, or follow-up referral needs.
• Initiate and discontinue 5150 custodial holds within NorthBay Medical Center and VacaValley Emergency Rooms, and inpatient units.
• Collaborate with interdisciplinary healthcare staff to manage psychosocially complex patients by completing clinical bio-psychosocial assessments, formulating individualized plans of care, developing discharge plans, monitoring progress, and identifying barriers to meeting estimated length of stay.
• Facilitate integration with community-based resources to optimize patient health and communicate relevant information to care providers across the continuum of care.
• Document assessments and interventions in the patient’s medical record in compliance with applicable regulations and system policies.

Primary job duties

• Perform comprehensive psychosocial evaluations including presenting problems, history of present illness, medical history, psychosocial history, mental status evaluation, and diagnosis consistent with department policies and procedures.
• Initiate or discontinue 5150 custodial holds within NorthBay Medical Center and VacaValley Emergency Rooms, and inpatient units.
• Partner with physicians, nurses, and other team members to establish, document, implement, and evaluate individualized plans of care.
• Bring clinical assessment skills, acute and long-term health expertise, learning theory, and multidisciplinary team expertise to the interdisciplinary team.
• Monitor progress of the plan of care and communicate changes with the care team.
• Develop discharge plans for assigned caseload, including arranging placement, home care, and community resources.
• For California Children’s Services (CCS) identified patients, oversee aspects of discharge planning in collaboration with a CCS-paneled MSW/LCSW and the multidisciplinary team.
• Manage psychosocially complex patients and families across the continuum of care, providing integrated mind-body-spirit services through a mutually agreed-upon plan of care.
• Support system processes related to patient health management across the continuum of care, including quality improvement, clinical practice team membership, clinical research, quality monitoring, and community networking.
• Assess and reassess patient and family needs, conceptualizing problem situations within the social work scope of service using age-appropriate skills.
• Develop and maintain a collaborative relationship with Solano County Behavioral Health, assist with coordination and placement of 5150 patients using county resources and/or the All-Access Transfer Center.
• Provide direct clinical social work services and counseling to patients and families, interpreting social, psychological, emotional, financial, and family issues to attending physicians and healthcare team members.
• Complete required documentation in the patient’s medical record on department forms and in Cerner.
• Develop and provide in-services as requested and function as a community liaison as assigned, working with Solano County Behavioral Health and related resources.
• Identify and apply knowledge of legal mandates including scope of practice, privileged communication, confidentiality, reporting requirements, professional conduct, and other mandates.
• Demonstrate continued enhancement of clinical professional skills and comply with department and hospital policies and procedures.

Qualifications

• Education: Master of Social Work from a CSWE-accredited program.
• Licensure: California Board of Behavioral Sciences Licensed Clinical Social Worker (LCSW). CCS paneling required if working with pediatric/NICU populations.
• Experience: Minimum of two years’ experience in an acute healthcare or community health setting.

Skills

• Strong clinical assessment skills.
• Excellent interpersonal and communication skills: verbal, written, and listening.
• Strong critical thinking and independent judgment with clinical decision-making ability.
• Excellent follow-through and organizational skills; ability to manage concurrent activities, set realistic goals, and meet deadlines without compromising quality.
• Ability to work effectively with diverse populations and direct others to accomplish tasks.
• Knowledge of individual, child, and family development; human behavior; culture; psychotherapy; case management; and the relation between social work practice and medicine.
• Skilled at working with patients and families coping with loss and grief.
• Knowledge of child, elder, and dependent adult abuse and domestic violence reporting requirements; understanding of Tarasoff, HIPAA, and other relevant laws.
• Ability to assess lethality, develop appropriate treatment plans, and use DSM-5 effectively.
• Knowledge of legal requirements for psychiatric services including 5150 holds and ability to manage conflict.
• Basic proficiency with word processing; experience with Cerner and PowerPoint preferred.
• Preferred knowledge of acute care, subacute care, long-term care, home care, hospice, rehabilitation options, county mental health services, and community resources.