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Advanced Care Planning (ACP) Nurse Practitioner

The Advanced Care Planning (ACP) Nurse Practitioner is the clinical anchor of the ACP program within Duly Health and Care's Value-Based Care population. This role provides advanced practice clinical judgment for the most complex serious illness, goals of care, and code status conversations, working in close partnership with the ACP Social Worker, who serves as the program's primary engagement and volume driver.

The ACP Nurse Practitioner receives warm escalations from the ACP Social Worker for medically complex patients, disputed or ambiguous code status, uncertain prognosis discussions, and cases requiring APRN-level clinical assessment and decision-making. This role conducts in-depth goals of care visits, reconciles clinical status with patient preferences, and translates those preferences into actionable medical orders, including POLST completion and code status orders in Epic.

Essential Responsibilities Complex Goals of Care Management

• Serve as the receiving clinician for ACP Social Worker escalations, managing a panel of medically complex patients requiring APRN-level goals of care and code status discussions.
• Conduct in-depth, patient- and family-centered goals of care visits via telephonic, video, or in-person encounters, integrating clinical status, prognosis, and treatment options into the conversation.
• Resolve disputed or ambiguous code status by reconciling clinical trajectory with patient and family preferences, in consultation with the PCP or specialist of record as needed.
• Manage a defined caseload of escalated and high-complexity patients with structured productivity expectations aligned to the ACP program.

Clinical Order Facilitation

• Complete and sign POLST forms, code status orders, and other medical orders reflecting documented patient preferences, consistent with Illinois APRN scope of practice.
• Review and interpret clinical documentation, diagnoses, and prognosis to inform and ground goals of care conversations in accurate medical context.
• Order or coordinate palliative care and hospice evaluations when clinically indicated, and confirm alignment between medical orders and completed advance directives.
• Ensure all medical orders and clinical documentation are entered, linked, and visible in Epic and communicated to the primary care team.

Hospice & Palliative Care Clinical Oversight

• Evaluate escalated patients for hospice and palliative care appropriateness using clinical criteria, and confirm eligibility in partnership with the referring social worker.
• Provide clinical consultation to the care team on prognosis, symptom burden, and disease trajectory to support hospice and palliative care decision-making.
• Facilitate warm handoffs to hospice agencies, palliative care programs, and specialist consultation when clinically appropriate.
• Serve as a clinical resource for hospice and palliative care questions raised by the ACP Social Worker and broader care management team.

Partnership with the ACP Social Worker

• Maintain a closed-loop escalation process with the ACP Social Worker — confirming receipt of escalations, reviewing conversation context, and documenting the outcome of each APRN visit.
• Provide timely feedback and follow-up to the referring social worker so non-clinical follow-up, directive completion, and psychosocial support can continue seamlessly.
• Participate jointly with the ACP Social Worker in interdisciplinary case conferences, high-risk rounds, and care team huddles to identify patients appropriate for APRN-level engagement.
• Offer clinical education and case consultation to the ACP Social Worker and care management team on prognosis, disease trajectory, and complex symptom management.

Care Team Collaboration

• Partner with PCPs, specialists, Care Allies, and Care Coordinators to ensure goals of care and code status orders are integrated into the broader care plan.
• Collaborate with transitional care and discharge planning teams to engage patients following hospitalization, a key moment of clinical change and receptivity.
• Support PCPs by providing specialized ACP clinical expertise for patients whose complexity exceeds routine primary care goals of care discussions.
• Represent the ACP program in clinical forums, contributing APRN perspective to program design and quality improvement.

Documentation & Compliance

• Complete timely, accurate Epic documentation for all APRN encounters, including clinical assessment, goals of care discussion content, orders placed, and escalation outcomes.
• Maintain compliance with all regulatory, payer, licensure, and organizational requirements related to APRN practice, prescriptive authority, and ACP documentation.
• Ensure documentation supports quality metrics and value-based care reporting requirements for the ACP program.

Qualifications Required

• Active Advanced Practice Registered Nurse (APRN) license in Illinois, with national certification as a Nurse Practitioner (FNP, AGPCNP, AGACNP, or equivalent).
• Clinical experience as a Nurse Practitioner in a healthcare, hospital, palliative care, or geriatric care setting preferred.
• Experience conducting serious illness, goals of care, or end-of-life conversations, and comfort making independent clinical judgments regarding prognosis and code status.
• Current DEA registration and prescriptive authority, or eligibility to obtain.
• Demonstrated ability to manage an escalation-based caseload with structured clinical productivity expectations.
• Strong communication, motivational interviewing, and interdisciplinary collaboration skills, particularly in partnership with social work colleagues.
• Comfort working within a multidisciplinary care team and in a matrixed clinical environment.

Preferred

• 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).
• Board certification or focused training in Palliative Care or Hospice and Palliative Medicine (e.g., ACHPN).
• Knowledge of Medicare Advantage, MSSP, ACO, and population health care models.
• Proficiency with Epic EMR.
• Bilingual or multilingual capability preferred given patient population diversity.

Compensation & Benefits The anticipated base compensation range for this position is 100,000k-140,000k, depending upon the applicant's qualifications and experience. In addition to the base compensation, this position may also be eligible for a sign-on bonus. Additional Benefits Include:

• 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
• Immediate 401K match
• Paid time off
• A culture committed to community engagement and social impact
• Employee discounts and tuition assistance
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for full-time non-physician team members once eligibility requirements are met.

Artificial Intelligence Disclosure- Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.