ACP RN: Patient-Centered Care Coordinator

Avera; 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 and mentorship

Job summary

Avera is seeking a Registered Nurse to provide skilled, patient-centered care coordination for patients with complex or advanced illness needs in Sioux Falls, SD. You will work with families, providers, social workers, and care management to ensure care aligns with patient goals and values.

Responsibilities include ACP discussions, education on directives, and coordinating referrals across palliative care, hospice, and other services.

Qualifications

• Active RN license in the state of practice.
• Advance Care Curriculum Certification within 180 days.
• Clinical nursing experience in care coordination, case management, chronic disease management, hospital, primary care, oncology, hospice, or palliative care.

Responsibilities

• Conduct comprehensive nursing assessments for patients with complex or advanced illness.
• Prepare patients and families for Advance Care Planning discussions.
• Provide education on advanced directives and POLST forms.
• Serve as a clinical contact and advocate throughout the care pathway.
• Promote documentation of patient wishes in the EMR and ensure accessibility across settings.
• Collaborate with IT to develop EMR ACP care pathway functionality.
• Coordinate referrals to palliative care, hospice, social services, and other supports.

Skills

RN License

Advance Care Curriculum Certification

Care coordination

Goals-of-care conversations

Interdisciplinary team

Communication

Education

Registered Nurse (RN) - Board of Nursing

Advance Care Curriculum Certification

Bachelor's degree in nursing

Job description

Avera is seeking a Registered Nurse to provide skilled, patient-centered care coordination for patients with complex or advanced illness needs in Sioux Falls, SD. You will work with families, providers, social workers, and care management to ensure care aligns with patient goals and values.

Responsibilities include ACP discussions, education on directives, and coordinating referrals across palliative care, hospice, and other services.