ACP Social Worker - Shared Decision Making

Duly Health and Care; Northern (KY); Hybrid; USD 58,000 - 75,000; Full time

Benefits offered by this job

Comprehensive medical, dental, and视?ck

Mental health benefit

Employer provided life and disability

Tuition Reimbursement $5,250 per year

Immediate 401(k) match

Paid volunteer time off (40 hours)

Job summary

Duly Health and Care in Illinois seeks an Advanced Care Planning (ACP) Social Worker to lead patient-centered conversations across the Value-Based Care population. You will identify patients, initiate conversations, and document directives and referrals in Epic.

You will conduct ACP conversations daily, facilitate advance directives, Living Wills and Healthcare Power of Attorney, and collaborate with care teams to align care with patient wishes. Epic EMR proficiency preferred.

Qualifications

• Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) in Illinois.
• Minimum 2 years of clinical social work experience in healthcare.
• Experience conducting serious illness, end-of-life, or goals of care conversations.
• Ability to manage a caseload with structured daily productivity expectations.
• Strong motivational interviewing and active listening skills.
• Comfort working within a multidisciplinary care team and in a matrixed environment.

Responsibilities

• ACP Engagement: conduct 8+ ACP conversations daily across channels.
• Advance Directive Facilitation: guide completion of directives and related documents.
• Hospice & Palliative: identify referrals and initiate conversations with care team.
• Escalation to ACP Advanced Practice Provider (APP) for high-complexity cases.
• Psychosocial Assessment & Support: assess barriers and provide counseling.
• Care Team Collaboration: partner with care teams to integrate ACP into management.
• Documentation & Compliance: maintain Epic documentation and regulatory compliance.

Skills

LCSW/LSW IL licensure

Clinical social work

Motivational interviewing

Active listening

Epic EMR proficiency

Tools

Epic EMR

Job description

Duly Health and Care in Illinois seeks an Advanced Care Planning (ACP) Social Worker to lead patient-centered conversations across the Value-Based Care population. You will identify patients, initiate conversations, and document directives and referrals in Epic.

You will conduct ACP conversations daily, facilitate advance directives, Living Wills and Healthcare Power of Attorney, and collaborate with care teams to align care with patient wishes. Epic EMR proficiency preferred.