Northbay Health is seeking a Medical Social Worker to join our team in Fairfield, CA, supporting our inpatient hospital units and broader care coordination efforts. This role is essential in improving patient outcomes through clinical intervention, education, and continuity of care across both inpatient and outpatient settings. This role plays a key part in identifying patients at risk for readmission and ensuring seamless transitions across the continuum of care. JOB SUMMARY Provides psychosocial assessment, case management, crisis intervention and care coordination services to patients receiving treatment for substance use disorders withing an addiction medicine clinic. This includes assessment and documentation of emotional, social, financial, environmental or follow-up referral needs under the guidance. Works collaboratively with the interdisciplinary teams and Population health including physicians, pharmacy, counselors, and peer recovery specialists to support patients engagement in treatment, recovery and long-term stability. Formulates a psychosocial plan of care related to assessment of patient's unique strengths and needs. Facilitates integration with community-based resources to optimize patient health. Activities are consistent with System mission and values and in compliance with applicable regulations and System policies and procedures. PRIMARY JOB DUTIES Partners with the Addiction Medicine provider, Population Health, pharmacist, physicians, nursing, and other members of the healthcare team to establish, document, implement and evaluate a plan of care based on the patient's unique health strengths and needs. Brings psychological assessment skills; acute, long term, and community health expertise; learning theory; and multidisciplinary team expertise to the interdisciplinary team. Monitors progress of the care plan and communicates any changes with the care team. To the extent possible, provides integrated - mind, body, spirit - service to the patient and family through a mutually agreed upon plan of care and patient advocate relationship. Supports System processes related to the health management of patients across the continuum of care, e.g. QI and/or clinical practice team membership, clinical research, quality monitoring, community networking. Assesses needs of patients/families and conceptualizes problem situations within social work scope of service using appropriate age-related skills. Provides direct social work services and counseling to patients and their families. Interprets social, psychological, emotional, financial and family issues for Addiction Medicine provider and other members of the interdisciplinary team. Completes documentation required in EMR patient's medical record. Develop in-services and community liaison work as assigned. Identifies and applies knowledge of legal mandates such as scope of practice, privileged communication, confidentiality, reporting requirements, professional conduct and other mandates. Demonstrates continued enhancement of professional skills. Complies with department and hospital policies and procedures Demonstrates commitment to quality of service. Supports organization goals to provide the best/optimal care to our patients and families, and community to our highest customer satisfaction. Performs other duties as assigned.
