Phone-based Advance Care Planning Social Worker

Sioux Center Health; Sioux Center (IA); On-site; USD 35,000 - 53,000; Full time

Benefits offered by this job

PTO from day 1

Employer matching retirement up to 5%

Career development mentorship

Job summary

Avera is seeking a Social Work professional to coordinate Advance Care Planning services across ambulatory clinic settings. You will lead discussions with patients and families about goals of care, coordinates with care teams, and promote patient‑centered planning across the continuum.

You will provide education, ensure documentation compliance, and monitor outcomes to improve care transitions and align with value‑based care initiatives.

Qualifications

• The ability to communicate effectively with patients, families, and care teams.
• Strong understanding of ethics, advance directives, and patient rights.
• Experience with care coordination and social work in healthcare settings.

Responsibilities

• Develops and implements Advance Care Planning programs across clinics.
• Facilitates ACP discussions with patients and designated decision makers.
• Collaborates with providers, hospice, palliative care, and teams for high‑need patients.
• Provides education and support on ACP principles and documentation.
• Maintains communication with clinics and community partners to promote transitions of care.
• Leads efforts to improve access to ACP services and ensure patient wishes are honored.
• Contributes to educational materials and care pathways supporting person‑centered care.
• Monitors outcomes and quality metrics related to ACP and patient engagement.
• Serves as liaison among patients, families, physicians, and healthcare facilities.

Skills

Communication

Care coordination

Interdisciplinary teamwork

Education

Bachelor's in Social Work

Social Work license (state)

Advance Care Curriculum Certification

Job description

Avera is seeking a Social Work professional to coordinate Advance Care Planning services across ambulatory clinic settings. You will lead discussions with patients and families about goals of care, coordinates with care teams, and promote patient‑centered planning across the continuum.

You will provide education, ensure documentation compliance, and monitor outcomes to improve care transitions and align with value‑based care initiatives.