Advanced Care Planning- RN

Avera-Healt; Sioux Falls (SD); On-site; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO from day 1

5% retirement matching

Career development/mentorship

Job summary

Avera is seeking an RN to provide skilled, patient‑centered care coordination for patients with complex, chronic, or advanced illnesses. The RN collaborates with families, providers, and care teams to ensure care aligns with patient goals and is documented in the EMR.

Responsibilities include ACP discussions, education on advance directives, and coordinating services across the care continuum. The role emphasizes working with AMGs and interdisciplinary teams, promoting patient advocacy, and

Qualifications

• RN license active in practicing state required.
• Experience with goals‑of‑care conversations and advance care planning.
• Experience in care coordination, palliative care or hospice settings.

Responsibilities

• Conduct comprehensive nursing assessments for patients with complex, chronic, serious, or advanced illness.
• Prepare patients and families for ACP discussions and document patient wishes in EMR.
• Coordinate referrals to palliative care, hospice, social services, and spiritual care; act as clinical liaison across teams.

Skills

Communication skills

Visual acuity

Interdisciplinary teamwork

Education

RN license in state of practice

Advance Care Curriculum Certification

Tools

EMR systems

Job description

Location:Avera Downtown Building-Sioux FallsWorker Type:RegularWork 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 - $46.25Position HighlightsYou Belong at AveraBe 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 OverviewProvides 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 doConducts 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 QualificationsThe 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 HireAdvance Care Curriculum Certification - Respecting Choices within 180 DaysClinical 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 needsExperience with goals-of-care conversations, advance care planning, palliative care or hospiceExperience working within an interdisciplinary care modelPreferred Education, License/Certification, or Work Experience:Bachelor's in nursingExpectations and StandardsCommitment 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 SomeAvera 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 retirementCareer development guided by hands-on training and mentorshipAvera 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].