Social Worker (MSW) | Advanced Care Planning

Avera•Sioux Falls, SD

10d•Onsite

About The Position

The Social Worker (MSW) coordinates and implements Advance Care Planning (ACP) services across Avera ambulatory clinic settings for a high-yield patient population. The role facilitates discussions about patients’ goals, values, and preferences for future healthcare decisions, and provides education, counseling, care coordination, and consultation to patients, families, providers, and community partners on advance directives and end-of-life planning. The social worker serves as a subject matter expert and resource to promote patient-centered care, improve care transitions, and support value-based care initiatives across the Avera continuum. The position is based at Avera Downtown Building in Sioux Falls. It is a regular day-shift role with hours Monday through Friday, 8 a.m. to 5 p.m.; the person will primarily work with clients by phone. The posted pay range is $29.25–$44.00, with the actual rate dependent on experience.

Requirements

Master’s degree in Social Work.
Active Social Worker license from the licensing board in the state of practice, required upon hire.
At least 3 years of experience in healthcare, care management, hospice, palliative care, 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 advance care planning and goals-of-care discussions.
Experience working within an interdisciplinary care model.
Ability to work the specified hours.
Ability to perform essential job functions, including adequate visual acuity for position duties and effective communication, hearing, understanding, and distinguishing speech and other sounds.
Commitment to confidentiality, teamwork, and applicable safety requirements.

Responsibilities

Develop and maintain Advance Care Planning programs and processes throughout Avera primary care clinics, including documentation standards, quality metrics, educational resources, and reporting methods focused on patient-centered outcomes, patient experience, and care quality.
Facilitate 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.
Collaborate 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.
Provide consultation, education, and support to patients, families, healthcare teams, and community partners regarding Advance Care Planning principles, documentation requirements, ethical considerations, and patient rights.
Maintain communication with clinics, hospitals, home health, hospice, Avera’s SNF (Skilled Nursing Facility) Post Acute Network Liaison, and community organizations to promote seamless care transitions and consistent Advance Care Planning practices.
Lead efforts to improve access to Advance Care Planning services and ensure patient wishes are documented, communicated, and honored across care settings.
Assist with developing and implementing educational materials, workflows, Epic care pathway build, and best practices that support person-centered care and informed healthcare decision-making.
Monitor Advance Care Planning program outcomes and quality measures, including advance directive completion rates and patient engagement metrics.
Serve as a liaison among patients, families, physicians, care teams, community organizations, and healthcare facilities to support coordinated, goal-concordant care.
Maintain confidentiality and work effectively with team members to coordinate workflow and support a productive and efficient environment.
Comply with applicable safety principles, laws, regulations, and standards, including CMS, The Joint Commission, DHHS, and OSHA requirements where applicable.
Apply Avera’s mission, vision, core values, and social principles in daily work; promote compassion, hospitality, and stewardship; and uphold CARE standards of Communication, Attitude, Responsiveness, and Engagement.