Registered Nurse Advance Care Planning

Job Description:

The Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for assessing, planning, implementing and evaluating care of patients. The staff RN utilizes the nursing process by use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members.

The RN Advance Care Planning Facilitator serves as a clinical expert in advance care planning, serious illness communication, and patient-centered decision making. This role facilitates advance care planning conversations, supports completion of advance directives and POLST/POST/MOST documents, provides caregiver education and training, and promotes system-wide adoption of advance care planning best practices. The facilitator works collaboratively with primary care, specialty care, palliative care, care management, social work, and community partners to ensure patients' healthcare preferences are understood, documented, and accessible.

• Facilitate advance care planning conversations with patients and families.
• Assist patients with completion of advance directives and state-specific ACP documents.
• Facilitate POLST/POST/MOST discussions consistent with organizational policies and state regulations.
• Provide education regarding goals of care, surrogate decision makers, and treatment preferences.
• Support centralized ACP referral processes and patient outreach activities.
• Conduct ACP facilitator training programs and competency validation.
• Educate caregivers and clinical teams on ACP workflows, documentation standards, and communication skills.
• Review ACP documentation quality and work collaboratively with HIM and clinical teams to improve documentation accuracy.
• Participate in quality improvement initiatives, data collection, reporting, and program evaluation activities.
• Serve as a consultant and resource for ACP practices across the organization.
• Collaborate with palliative care leaders on ACP strategy, implementation, and program growth.

• Current Registered Nurse license.
• Minimum three years of RN experience, including acute, care management, hospice, and palliative care.
• Experience facilitating goals-of-care or serious illness conversations.
• Strong communication, presentation, and education skills.
• Demonstrated ability to work independently and collaboratively across multidisciplinary teams.
• Experience with electronic medical record documentation.

• Palliative care, hospice, care management, oncology, geriatrics, or chronic disease management experience.
• Advance Care Planning Facilitator Certification.
• Respecting Choices certification or equivalent ACP training.
• Experience developing educational materials and training programs.
• Quality improvement or program development experience.

• Serious illness communication.
• Advance care planning facilitation.
• Adult learning principles.
• Group facilitation and public speaking.
• Change management and workflow implementation.
• Conflict management and mediation.
• Clinical documentation and EMR proficiency.
• Ability to communicate with patients, providers, and caregivers.

• Full-time position.
• Monday through Friday
• 9:00a - 5:30p
• Hybrid work environment with virtual and in-person patient and caregiver interactions.
• May support multiple regions and care settings across ambulatory and inpatient environments.

• Ability to read information, labels, monitors, and patient documentation, and assess patient needs.
• Frequent verbal communication with patients, visitors, and care team members, including responding to alarms and urgent situations.
• Manual dexterity to operate medical equipment, administer care, and use…