Social Worker (MSW) | Advanced Care Planning

Avera; Sioux Falls (SD); On-site; USD 40,000 - 61,000; Full time

Benefits offered by this job

PTO from day 1

Retirement match up to 5%

Career development

Job summary

Avera Downtown Building in Sioux Falls seeks a Social Worker to coordinate and implement Advance Care Planning across ambulatory clinics, guiding patients and families through goals, values, and end-of-life preferences with education, care coordination, and collaboration.

This role leads ACP programs, collaborates with providers and teams, documents standards, and monitors outcomes to improve transitions and patient-centered care.

Qualifications

• Master's in Social Work is required.
• Active Social Work license in the practicing state.
• Advance Care Curriculum Certification required.
• Minimum of 3 years in healthcare, care management, hospice, palliative, or serious illness care.
• Knowledge of healthcare ethics, advance directives, and relevant regulations.
• Experience with psychosocial assessment and care coordination.
• Experience with advance care planning and goals-of-care discussions.
• Experience working in an interdisciplinary care model.

Responsibilities

• Develops and coordinates Advance Care Planning programs across primary care clinics.
• Facilitates ACP discussions with patients and designated decision-makers.
• Collaborates with providers and care teams to identify patients who may benefit from ACP services.
• Provides education and support on ACP principles to patients, families, and healthcare teams.
• Maintains communication with clinics and community partners to promote seamless transitions of care.
• Leads efforts to improve access to ACP services and documentation.
• Supports development of educational materials and Epic care pathway builds.
• Monitors outcomes and quality measures related to ACP.

Skills

Communication skills

Care coordination

Interdisciplinary teamwork

Education

Master's in Social Work

Active Social Work license (State)

Advance Care Curriculum Certification

Healthcare sector experience

Tools

Epic

Job description

Sioux Falls, SD

Full time

R-260030295

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.

$29.25 - $44.00

Position Highlights

Hours are M-F 8-5. This person will primarily work with clients over the phone.

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

• Master'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

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.

The policy of Avera to provide opportunities for all qualified employees or applicants without regard to disability and to provide reasonable accommodations for all employees or applicants who may be disabled. Avera is committed to ensuring compliance in accordance with the Americans with Disability Act. For assistance, please contact HR Now at 605-504-4444.

Additional Notices

For TTY, dial 711

Avera is an Equal Opportunity/Affirmative Action Employer: Minority/Female/Disabled/Veteran/Sexual Orientation/Gender Identity.