Social Worker, Shared Decision Making

Duly Health and Care • Bountiful, UT

31d • $58,000 - $75,000 • Hybrid

About The Position

At Duly Health and Care, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.
The Advanced Care Planning (ACP) Social Worker is responsible for driving patient-centered serious illness conversations across Duly Health and Care's Value-Based Care population. This role serves as the primary point of engagement for advance care planning, ensuring patients with serious illness, multiple chronic conditions, or end-of-life care needs are identified, engaged, and supported in completing advance directives and goals of care documentation.
The ACP Social Worker conducts a minimum of 8 ACP conversations per day, through structured outreach, telephonic and in-person engagement, and care team collaboration. This role serves as the primary driver of ACP volume across the program — identifying patients, initiating conversations, completing advance directive documentation, facilitating hospice and palliative care referrals, and escalating high-complexity cases to the ACP Advanced Practice Provider (APP) for clinical management.
This position is critical to Duly's Value-Based Care strategy. By proactively engaging patients in advance care planning, the ACP Social Worker reduces unwanted utilization, supports patient-centered decision-making, and ensures care delivered at end of life is consistent with each patient's stated wishes.

Requirements

• Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) in Illinois.
• Minimum 2 years of clinical social work experience in a healthcare, hospital, or community health setting.
• Experience conducting serious illness, end-of-life, or goals of care conversations with patients and families.
• Demonstrated ability to manage a caseload with structured daily productivity expectations.
• Strong motivational interviewing, patient engagement, and active listening skills.
• Comfort working within a multidisciplinary care team and in a matrixed clinical environment.

Nice To Haves

• Experience in Palliative Care, Hospice, Geriatrics, Care Management, or Value-Based Care settings.
• Advance Care Planning training, certification, or formal program experience (e.g., Respecting Choices, VitalTalk).
• Knowledge of Medicare Advantage, MSSP, ACO, and population health care models.
• Proficiency with Epic EMR.
• Bilingual or multilingual capability preferred given patient population diversity.

Responsibilities

• Conduct a minimum of 8 advance care planning conversations per day across telephonic, in-person, and care team-facilitated channels.
• Manage an active ACP outreach panel, maintaining consistent follow-up cadence for patients requiring multiple touchpoints before directive completion.
• Meet or exceed monthly ACP conversation volume and advance directive completion targets as defined by the program.
• Document all ACP conversations, patient preferences, and advance directive status in Epic in accordance with organizational standards.
• Guide patients and families through completion of Advance Directives, Living Wills, and Healthcare Power of Attorney documentation.
• Educate patients on the difference between advance directives, POLST, DNR orders, and goals of care documentation in accessible, culturally sensitive language.
• Ensure completed documents are uploaded, linked, and visible in Epic and communicated to the primary care team.
• Support patients who are revising or updating existing directives due to changes in health status or preferences.
• Identify patients who may be appropriate for hospice or palliative care consultation and initiate referral conversations with the patient, family, and care team.
• Educate patients and caregivers on the hospice and palliative care benefit — eligibility criteria, services available, and how it aligns with their stated goals.
• Facilitate warm handoffs to hospice agencies, palliative care programs, and community-based supportive services.
• Track hospice referral outcomes and follow up to ensure patients are connected to appropriate care.
• Screen patients during ACP conversations to identify clinical complexity warranting APP involvement — including medically complex cases, disputed code status, ambiguous prognosis discussions, or patients requiring NP/PA-level clinical judgment.
• Execute warm escalations to the ACP APP for high-complexity goals of care cases, ensuring continuity of conversation context and documentation.
• Maintain a closed-loop escalation process — confirming APP engagement, documenting handoff, and following up post-APP visit as needed.
• Serve as the APP's primary referral pipeline, maximizing APP clinical time by filtering volume and surfacing only appropriate complex cases.
• Assess patients and caregivers for psychosocial barriers to ACP engagement including fear, grief, family conflict, cognitive decline, cultural factors, and health literacy.
• Provide brief, solution-focused counseling and motivational interviewing to support readiness for ACP conversations.
• Connect patients and families with community resources, bereavement support, caregiver assistance, and social service programs as needed.
• Identify and address social determinants of health that may affect a patient's ability to execute their care preferences.
• Partner with Care Allies, Care Coordinators, Discharge Coordinators, and PCPs to identify patients appropriate for ACP engagement and integrate ACP into existing care management touchpoints.
• Participate in interdisciplinary case conferences, high-risk rounds, and care team huddles to surface patients in need of ACP intervention.
• Collaborate with transitional care and discharge planning teams to engage patients following hospitalization — a key moment of receptivity for ACP conversations.
• Serve as an ACP resource and educator for the broader care management team.
• Complete timely, accurate Epic documentation for all ACP encounters, including conversation content, patient preferences expressed, directives completed, referrals made, and escalations to APP.
• Maintain compliance with all regulatory, payer, licensure, and organizational requirements related to social work practice and ACP documentation.

Benefits

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed