Advanced Care Planning- RN

Avera Health; 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 through training &

Job summary

Avera Health in Sioux Falls, SD seeks a Registered Nurse to provide skilled care coordination and clinical support for patients with complex and advanced illness needs. You will work with an interdisciplinary team to ensure care is aligned with patient goals and preferences.

Responsibilities include ACP discussions, education on directives, and coordinating referrals to palliative care and social services. A BSN is preferred; valid RN license required; experience in care coordination preferred.

Qualifications

• Active RN license in state of practice.
• Experience in care coordination or chronic disease management.
• Experience with goals-of-care conversations and advance care planning.

Responsibilities

• Conducts comprehensive nursing assessments for patients with complex needs.
• Prepares patients and families for ACP discussions on goals and treatment preferences.
• Educates on advanced directives, power of attorney, living wills and POLST forms.
• Serves as a consistent clinical contact and advocate throughout the care pathway.
• Coordinates referrals to palliative care, hospice and other support services.

Skills

Care coordination

Interdisciplinary collaboration

Patient education

Communication skills

Education

RN license

BSN preferred

Tools

EMR systems

Job description

Location: Avera Downtown Building-Sioux Falls

Worker Type: Regular Work Shift: Primarily days with possible weekends/evenings/holidays (United States of America)

Pay Range: The pay range for this position is listed below. Actual pay rate dependent upon experience. $31.00 - $46.25

Position Highlights

You Belong at Avera Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Provides skilled, patient-centered care coordination and clinical support for patients with complex, chronic, serious, or advanced illness needs. The RN works collaboratively with patients, families, providers, social workers, care management teams, and other members of the interdisciplinary care team to ensure that care is coordinated, appropriate, timely, and aligned with the patient's goals, values, and treatment preferences. Collaborates with the Avera Medical Group (AMG) population health team to identify patients who may benefit from Advanced Care Planning services.

What you will do

Conducts comprehensive nursing assessments of patients with complex, chronic, serious, or advanced illness while identifying patients who may benefit from Advance Care Planning (ACP) services, including individuals with chronic illness, serious illness, advanced age, multiple hospitalizations, or complex healthcare needs.

Prepares patients and families for Advance Care Planning discussions regarding healthcare goals, values, preferences, and future medical decisions to assist patients and families in understanding treatment options and making informed healthcare decisions.

Provides education regarding advanced directives, healthcare power of attorney, living wills, Physician Orders for Life-Sustaining Treatment (POLST) forms, and other Advance Care Planning documents.

Serves as a consistent clinical contact and advocate for patients and families throughout the care pathway.

Promotes documentation of patient wishes within the electronic medical record and ensures accessibility of documents across care settings.

Works with IT to develop EMR functionality for an ACP care pathway, documentation standards, and tracking outcomes.

Collaborates proactively with providers, care managers, social workers, palliative care, Avera@Home, and interdisciplinary teams to identify patients who may benefit from Advance Care Planning services, particularly those with serious illness, chronic disease, or complex healthcare needs.

Collaborates with patients, families, providers, and community resources to ensure care plans align with patient preferences, including follow-up support for patients after Advance Care Planning visits or discussions.

Coordinates referrals to palliative care, hospice, social services, behavioral health, spiritual care, community resources and other support services as indicated.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

Registered Nurse (RN) - Board of Nursing

An active license in the state of practice Upon Hire Advance Care Curriculum Certification - Respecting Choices within 180 Days Clinical nursing experience, preferably in care coordination, case management, chronic disease management, hospital, primary care, oncology, hospice, palliative care, geriatrics, or another setting involving complex patient needs Experience with goals-of-care conversations, advance care planning, palliative care or hospice Experience working within an interdisciplinary care model

Preferred Education, License/Certification, or Work Experience:

Bachelor's in nursing Expectations and Standards Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community. Promote Avera's values of compassion, hospitality, and stewardship. Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity. Maintain confidentiality. Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment. Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits

You Need & Then Some Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement.
• Career development guided by hands-on training and mentorship.

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail]. At Avera, the way you are treated as an employee translates into the compassionate care you deliver to patients and team members. Because we consider health care a ministry, you can live out your faith, uphold the dignity and respect of all persons while not compromising high-quality services. Join us in making a positive impact on moving health forward.