ACP Social Worker: Lead Advance Care Planning

Midwest Physicians Administrative Services, LLC dba Duly Health and Care; Highland Oaks (GA); On-site; USD 58,000 - 75,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

Mental health benefit

Life and disability insurance

Tuition reimbursement

401(k) match

Volunteer time off

Community engagement culture

Parental leave & adoption/surrogacy

Job summary

Duly Health and Care is seeking an Advanced Care Planning Social Worker to drive ACP conversations within our Value‑Based Care population. You will engage patients with serious illness and complex conditions, coordinating advance directives and goals of care across care teams.

You will document thoroughly in Epic, facilitate hospice/palliative referrals, and escalate high‑complexity cases to the ACP Advanced Practice Provider. A compassionate, patient‑centered approach is essential.

Qualifications

• Minimum 2 years of clinical social work experience in healthcare, hospital, or community health setting.
• Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) in Illinois is required.
• Experience conducting serious illness, end-of-life, or goals of care conversations with patients and families.

Responsibilities

• Drive patient-centered serious illness conversations across value-based care population.
• Identify patients, initiate ACP conversations, complete directives and referrals.
• Document ACP encounters and directives in Epic per standards.
• Facilitate hospice and palliative care referrals and care team handoffs.
• Escalate high-complexity cases to ACP APP for management.

Skills

ACP conversations

Caseload management

Motivational interviewing

Epic documentation

Care coordination

Multidisciplinary team

Education

LCSW or LSW licensure (Illinois)

Tools

Epic EMR

Job description

Duly Health and Care is seeking an Advanced Care Planning Social Worker to drive ACP conversations within our Value‑Based Care population. You will engage patients with serious illness and complex conditions, coordinating advance directives and goals of care across care teams.

You will document thoroughly in Epic, facilitate hospice/palliative referrals, and escalate high‑complexity cases to the ACP Advanced Practice Provider. A compassionate, patient‑centered approach is essential.