Social Worker, Shared Decision Making

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.

• 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.

• 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…