ACP RN: Care Coordination for Advanced Illness

Avera Health; Sioux Falls (SD); On-site; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO available day 1 for eligible hires

Up to 5% employer matching retirement

Career development through training &

Job summary

Avera Health in Sioux Falls, SD seeks a Registered Nurse to provide skilled care coordination and clinical support for patients with complex and advanced illness needs. You will work with an interdisciplinary team to ensure care is aligned with patient goals and preferences.

Responsibilities include ACP discussions, education on directives, and coordinating referrals to palliative care and social services. A BSN is preferred; valid RN license required; experience in care coordination preferred.

Qualifications

• Active RN license in state of practice.
• Experience in care coordination or chronic disease management.
• Experience with goals-of-care conversations and advance care planning.

Responsibilities

• Conducts comprehensive nursing assessments for patients with complex needs.
• Prepares patients and families for ACP discussions on goals and treatment preferences.
• Educates on advanced directives, power of attorney, living wills and POLST forms.
• Serves as a consistent clinical contact and advocate throughout the care pathway.
• Coordinates referrals to palliative care, hospice and other support services.

Skills

Care coordination

Interdisciplinary collaboration

Patient education

Communication skills

Education

RN license

BSN preferred

Tools

EMR systems

Job description

Avera Health in Sioux Falls, SD seeks a Registered Nurse to provide skilled care coordination and clinical support for patients with complex and advanced illness needs. You will work with an interdisciplinary team to ensure care is aligned with patient goals and preferences.

Responsibilities include ACP discussions, education on directives, and coordinating referrals to palliative care and social services. A BSN is preferred; valid RN license required; experience in care coordination preferred.