Advanced Care Planning- RN

Advanced Care Planning Nurse

Location: Avera Downtown Building-Sioux Falls

Worker Type: Regular

Work Shift: Primarily days with possible weekends/evenings/holidays (United States of America)

Pay Range: $31.00 - $46.25

Position Highlights

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 Provides 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 Do

• Conducts 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, View email address on click.appcast.io, 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 Qualifications

• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire
• Advance Care Curriculum Certification - Respecting Choices within 180 Days
• Clinical 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 needs
• Experience with goals-of-care conversations, advance care planning, palliative care or hospice
• Experience working within an interdisciplinary care model

Preferred Education, License/Certification, or Work Experience:

• Bachelor's in nursing

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 View phone number on click.appcast.io or send an email to View email address on click.appcast.io.

Floyd Valley Healthcare / An Avera Affiliate