Post-Enrollment ACP Facilitator (RN or LSW), Remote - Bilingual Preferred



Austin, TX, USA
Posted on Thursday, May 4, 2023
Scheduled hours are between 30 and 39 hours per week and include most benefits.
Learn more about us at .
Iris Healthcare powered by Aledade, Inc is looking for a licensed RN or Social Worker with a background in Advance Care Planning/End of Life Care, to join our growing team. Advance Care Planning (ACP) is defined as a process that supports individuals in understanding, and sharing their values, goals and preferences for future medical care. These care decisions are then formally documented within an Advance Directive; a forward-thinking legal document that empowers individuals, their loved ones and their care teams to make the best advance care planning decisions moving forward.
Our interdisciplinary team walks the member through every step of the advance care planning process, from exploration of values through distribution and revision of necessary documents. The primary role of the Post-Enrollment Facilitator is to guide members through this conversation and document their preferences. These conversations include providing education on the patient’s primary medical condition and on such medical interventions as feeding tubes, ventilation, and CPR. Member encounters are conducted remotely via telephone.


  • To support work-life balance and fulfillment, this position offers flexibility in scheduling, is fully remote, and provides opportunities for advancement. The ideal candidate will:
  • Prepare for member encounters by reviewing EHR and pertinent notes.
  • Conduct structured, guided, advance care planning conversations in an empathetic manner consistent with person-centered care.
  • Draft Iris proprietary documents as well as state specific advance care planning documents utilizing Iris’ technology.
  • Document member encounters in the EHR.
  • Actively utilize 1:1 supervision, group supervision, team meetings and on-going learning and development offerings associated with the role
  • Provide ongoing feedback to supervisors regarding the member experience
  • Ongoing engagement with patients enrolled in Comprehensive Advance Care Planning (CACP). This includes but is not limited to follow up facilitations, managing large caseloads, periodic patient check ins, ongoing education/ document revisions, quick case conceptualization and ability to offer any CACP topic
  • Same Day/Straight Through Facilitations
  • SOS coverage (when needed & staff is able)


  • Must have active and unrestricted licensure as a Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW), meeting all state certification and licensing requirements for the state the candidate works in.
  • Minimum of two (2) years of nursing or social work experience related to management of chronic or terminal conditions in a healthcare setting.
  • Must be available to work Monday-Friday during regular business hours (flexible) and occasional evenings.
  • Demonstrated compassion and empathy
  • Excellent phone/video communication skills
  • Knowledge of serious medical conditions (such as COPD, CHF, cancer, dementia, cirrhosis, ESRD, etc.) and their progression
  • Demonstrated ability to collaborate and communicate effectively in an interdisciplinary team setting
  • Tech savvy
  • Experience in Motivational Interviewing preferred
  • Preference shown for expertise in advance care planning conversations or experience caring for those with serious illnesses in a longitudinal fashion (hospice/palliative care)
Who We Are:
Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of payers, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives, and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?
At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:
Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents, and domestic partners Robust time off plan 21 days of PTO in your first year 2 Paid Volunteer Days & 11 paid holidays
12 weeks paid Parental Leave for all new parents
6 weeks paid sabbatical after 6 years of service
Educational Assistant Program & Clinical Employee Reimbursement Program
401(K) with up to 4% match
Stock options
And much more!
At Aledade, we don’t just accept differences, we celebrate them! We strive to attract, develop, and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance, and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.
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