Advanced Care Planning RN — Care Coordination Specialist

Sioux Center Health; Sioux Center (IA); On-site; USD 43,000 - 64,000; Full time

Benefits offered by this job

PTO from day 1

RETIREMENT MATCHING 5%

Career development

Job summary

Avera is seeking a Registered Nurse for Advanced Care Planning and care coordination. The role involves collaborating with patients, families, providers and care teams to ensure care aligns with patient goals and values.

The RN will lead ACP discussions, educate on directives, coordinate referrals to palliative care and hospice, and support EMR documentation and care planning across settings.

Qualifications

• RN with active license in practice state
• Experience in care coordination or palliative care preferred
• Experience leading goals-of-care conversations and ACP

Responsibilities

• Conduct comprehensive nursing assessments of patients with complex needs
• Prepare patients and families for ACP discussions
• Educate on advance directives and POLST forms
• Serve as clinical contact and advocate across the care pathway
• Promote documentation of patient wishes in the EMR
• Collaborate with IT to develop ACP EMR pathways
• Coordinate referrals to palliative care, hospice and social services

Skills

Nursing assessments and care planning

Care coordination

Interdisciplinary teamwork

Advance care planning discussions

Education

RN license

Advance Care Curriculum Certification

Bachelor's in nursing

Tools

EMR documentation

Job description

Avera is seeking a Registered Nurse for Advanced Care Planning and care coordination. The role involves collaborating with patients, families, providers and care teams to ensure care aligns with patient goals and values.

The RN will lead ACP discussions, educate on directives, coordinate referrals to palliative care and hospice, and support EMR documentation and care planning across settings.