ACP Social Worker - Shared Decision Making

Duly Health and Care; Saint Petersburg (FL); On-site; USD 58,000 - 75,000; Full time

Benefits offered by this job

Tuition Reimbursement

401(k) Match

Volunteer time off

Job summary

Duly Health and Care is seeking an Advanced Care Planning (ACP) Social Worker to lead patient‑centered ACP conversations across the Value‑Based Care population. This role engages patients with serious illness to complete advance directives and goals of care documentation, coordinating with care teams and Epic documentation.

The ACP Social Worker conducts a minimum of 8 ACP conversations daily, guides directive completion, and facilitates hospice/palliative referrals while escalating complex

Qualifications

• Experience conducting serious illness, end-of-life, or goals of care conversations.
• Strong communication and interpersonal skills for patient and family engagement.
• Ability to manage a healthcare caseload within a multidisciplinary team.

Responsibilities

• Conduct ACP conversations with patients and families (8 per day).
• Document ACP encounters and directives in the Epic EMR.
• Identify patients for hospice/palliative care referrals and coordinate care.
• Escalate high‑complexity cases to the ACP Advanced Practice Provider.

Skills

Motivational interviewing

Active listening

Team collaboration

Education

Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) in Illinois

Job description

Duly Health and Care is seeking an Advanced Care Planning (ACP) Social Worker to lead patient‑centered ACP conversations across the Value‑Based Care population. This role engages patients with serious illness to complete advance directives and goals of care documentation, coordinating with care teams and Epic documentation.

The ACP Social Worker conducts a minimum of 8 ACP conversations daily, guides directive completion, and facilitates hospice/palliative referrals while escalating complex