Medical Social Worker (Full Time, Day) Job Listing at NorthBay Healthcare in Fairfield, CA (Job ID 4778)

Description

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.

The Medical Social Worker will primarily support inpatient hospital units, partnering closely with interdisciplinary teams to assess patient needs and implement interventions that enhance recovery and reduce readmissions. In collaboration with Population Health, this role will also extend into outpatient care by supporting high-utilizer patients through coordinated, team-based follow-up.

Responsibilities

• Conduct daily reviews of inpatient unit census to identify patients in need of social work intervention.
• Perform psychosocial assessments and develop care plans tailored to individual patient needs.
• Provide clinical intervention, counseling, and patient/family education to support optimal health outcomes.
• Identify barriers to discharge and coordinate appropriate resources and services.
• Collaborate with physicians, nurses, case managers, and interdisciplinary teams to ensure continuity of care.
• Partner with Population Health teams to support high-utilizer patients in outpatient settings.
• Facilitate smooth transitions from inpatient to outpatient care, reducing avoidable readmissions.
• Connect patients and families with community resources, including behavioral health, housing, transportation, and financial assistance.
• Maintain accurate, timely documentation in compliance with regulatory and organizational standards.

Education:  

• Master of Social Work from a school of Social Work accredited by the Council on Social Work Education.

Licensure/Certification:  

• California BBS Associate Clinical Social Worker (ASW) required.  
• ASW not required if grandfathered in with 40 years or more of social work experience.
• Licensed Clinical Social Worker (LCSW) preferred but not required for this position.

Experience:  

• Minimum of two year's experience within the acute health care setting or the community health setting, or intern or externship done at NorthBay HealthCare.

Skills:

• Strong psychosocial assessment skills.
• Strong critical thinking skills- must be capable of independent judgment, and have strong clinical decision-making skills.
• Skilled at working with patients and families coping with loss and grief.
• Excellent follow-through skills.
• Strong organizational skills with attention to detail required.
• Must have working knowledge of motivational theories, system theories, developmental theories, and group dynamics.
• Ability to work effectively with diverse populations, including those with respect to age, culture, ethnicity, and gender.
• Basic proficiency with word processing required; basic proficiency with databases strongly preferred.
• Must have strong written and oral communication skills.
• Hours of Work:

Based on business need.

• May have schedules consisting of: 7:45 am- 4:15 pm or 8:00 a.m. – 4:30 p.m. Monday –Friday.
• May require week-end and holiday coverage responsibilities, 8:00am – 4:30pm when needed.