ACP RN: Guide Goals of Care & Care Coordination

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

Benefits offered by this job

PTO from day 1

5% retirement matching

Career development/mentorship

Job summary

Avera is seeking an RN to provide skilled, patient‑centered care coordination for patients with complex, chronic, or advanced illnesses. The RN collaborates with families, providers, and care teams to ensure care aligns with patient goals and is documented in the EMR.

Responsibilities include ACP discussions, education on advance directives, and coordinating services across the care continuum. The role emphasizes working with AMGs and interdisciplinary teams, promoting patient advocacy, and

Qualifications

• RN license active in practicing state required.
• Experience with goals‑of‑care conversations and advance care planning.
• Experience in care coordination, palliative care or hospice settings.

Responsibilities

• Conduct comprehensive nursing assessments for patients with complex, chronic, serious, or advanced illness.
• Prepare patients and families for ACP discussions and document patient wishes in EMR.
• Coordinate referrals to palliative care, hospice, social services, and spiritual care; act as clinical liaison across teams.

Skills

Communication skills

Visual acuity

Interdisciplinary teamwork

Education

RN license in state of practice

Advance Care Curriculum Certification

Tools

EMR systems

Job description

Avera is seeking an RN to provide skilled, patient‑centered care coordination for patients with complex, chronic, or advanced illnesses. The RN collaborates with families, providers, and care teams to ensure care aligns with patient goals and is documented in the EMR.

Responsibilities include ACP discussions, education on advance directives, and coordinating services across the care continuum. The role emphasizes working with AMGs and interdisciplinary teams, promoting patient advocacy, and