Social Worker (BSW) | Advanced Care Planning

Avera Health; Sioux Falls (SD); On-site; USD 35,000 - 53,000; Full time

Benefits offered by this job

PTO day 1 for eligible hires

5% employer matching retirement plan

Career development and mentorship

Job summary

Avera Health is seeking a Social Worker to coordinate and implement Advance Care Planning across ambulatory clinics in Sioux Falls. The role involves facilitating goals-of-care discussions, documenting directives, and ensuring patient-centered care across settings.

Ideal candidates hold a Bachelor’s in Social Work, an active license, and ACP certification within 180 days. You will collaborate with physicians, care managers, hospice, and community partners to improve care transitions and outcomes.

Qualifications

• Bachelor's in Social Work required.
• Active license in state of practice.
• Advance Care Curriculum Certification within 180 days.

Responsibilities

• Develops and maintains Advance Care Planning programs across clinics.
• Facilitates ACP discussions with patients and families.
• Collaborates with care teams to identify patients who may benefit from ACP services.
• Provides education and support on ACP principles to patients and families.

Skills

Communication

Care coordination

Interdisciplinary collaboration

Empathy

Education

Bachelor's in Social Work

Active social work license

Advance Care Curriculum Certification

Job description

Location: Avera Downtown Building-Sioux Falls

Worker Type: Regular

Work Shift: Day Shift (United States of America)

Pay Range: The pay range for this position is listed below. Actual pay rate dependent upon experience. $25.50 - $38.25

Hours are M-F 8-5.

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

Coordinates and implements Advance Care Planning (ACP) services across Avera ambulatory clinic settings for high yield patient population. Facilitates discussions regarding patient goals, values, and preferences for future healthcare decisions. Provides education, counseling, care coordination, and consultation to patients, families, providers, and community partners regarding advance directives and end-of-life planning. Serves as a social work subject matter expert and resource to promote patient-centered care, improve care transitions, and support value-based care initiatives across the Avera continuum.

What you will do

• Develops and maintains Advance Care Planning programs and processes throughout Avera primary care clinics, including documentation standards, quality metrics, educational resources, and reporting methodologies focused on patient-centered outcomes, patient experience, and care quality.
• Facilitates Advance Care Planning discussions with patients, families, and designated healthcare decision-makers regarding goals of care, advance directives, healthcare power of attorney, POLST forms, Comfort One, and end-of-life treatment preferences.
• Collaborates proactively with providers, care managers, social workers, hospice, 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.
• Provides consultation, education, and support to patients, families, healthcare teams, and community partners regarding Advance Care Planning principles, documentation requirements, ethical considerations, and patient rights.
• Establishes and maintains ongoing communication with clinics, hospitals, home health, hospice, Avera’s SNF (Skilled Nursing Facility) Post Acute Network Liaison, and community organizations to promote seamless transitions of care and consistent Advance Care Planning practices.
• Leads efforts to improve access to Advance Care Planning services and ensure patient wishes are appropriately documented, communicated, and honored across care settings.
• Assists in the development and implementation of educational materials, workflows, Epic care pathway build, and best practices that support person-centered care and informed healthcare decision-making.
• Monitors program outcomes and quality measures related to Advance Care Planning, including completion rates of advanced directives and patient engagement metrics.
• Serves as a liaison between patients, families, physicians, care teams, community organizations and healthcare facilities to support coordinated, goal-concordant care.

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

• Bachelor's in Social Work
• Social Worker - Licensing Board an active license in the state of practice
• Upon Hire Advance Care Curriculum Certification - Respecting Choices within 180 Days
• Minimum of 3 years in healthcare, care management, hospice, palliative, or serious illness care
• Knowledge of healthcare ethics, advance directives, healthcare power of attorney, POLST forms, Comfort One forms, guardianship, and related state and federal regulations
• Experience providing psychosocial assessment, care coordination or resource navigation
• Experience with advanced care planning and goals-of-care discussions
• Experience working within an interdisciplinary care model

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

• 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.