What are the responsibilities and job description for the ANNUAL WELLNESS VISIT NURSE position at Covenant HealthCare?
Overview
The Annual Wellness Visit Nurse supports Care Connect as a passionate advocate for patient needs and is committed to helping patients navigate the healthcare system, integral to our mission. Role is responsible for conducting the Medicare Annual Wellness Visit (AWV) with patients to assess current health status, identify potential risks, develop personalized prevention plans, and coordinating necessary follow-up care. This individual works under the supervision of the Director Practice Transformation.
Works in collaboration with the primary care provider and all members of the health care team. May also assist clinic staff with completion of other clinical tasks as needed. Assesses healthcare needs that require additional follow up by primary care provider and assists patients in scheduling appropriate follow-up.
Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation.
Responsibilities
Patient assessment:
� Conducts onsite and telehealth Medicare Annual Wellness visits with eligible adult primary care patients. Responsible for a full patient schedule.
� Taking detailed health histories, performing basic physical assessments (like vital signs, height, weight), and reviewing medication lists.
Health risk assessment:
� Utilizing standardized tools to identify potential health concerns based on patient demographics, lifestyle factors, medical and family history.
� Identifies health risks, promotes healthy lifestyles, and provides wellness education.
Preventive care planning:
� Develop a customized prevention plan focused on prevention and detection for early health problems.
� Perform pre-visit planning to ensure appropriate follow-up and documentation of preventive screeners including health maintenance items.
� Discussing and scheduling necessary preventive screenings (cancer screenings, immunizations) and discussing lifestyle modifications.
Patient education:
� Providing information on health conditions, disease prevention, healthy lifestyle choices, and medication adherence.
Care coordination:
� Identifying and referring patients to specialists or community resources as needed, coordinating follow-up appointments, and communicating findings to other healthcare providers
Documentation:
� Maintains confidentiality of patient information according to established practice policies and government regulations, such as HIPAA.
� Accurately recording patient information, assessments, care plans, and interventions in the electronic medical record
� Ensures that documentation and billing of services performed is sufficient to meet CMS guidelines, correct coding guidelines and other payer quality incentive program guidelines.
Miscellaneous:
� Attends conferences, in-service programs and continuing education activities to meet the organization�s expectations.
� Follows Standard Precautions using personal protective equipment as required.
� Other duties, as assigned.
Qualifications
EDUCATION/EXPERIENCE
� Nursing Degree (ADN, Diploma, BSN) from an accredited school of nursing.
� License to practice professional nursing (RN) in the State of Michigan. BLS required.
� Experience with EPIC strongly preferred.
� Thorough understanding of Medicare guidelines regarding AWVs preferred.
KNOWLEDGE/SKILLS/ABILITIES
� Strong working knowledge of hospital operations and healthcare environment.
� Excellent written/oral communication interpersonal and leadership skills.
� Proficient customer service skills, time management and organizational skills, and self-directed.
� Ability to make quality, independent decisions while exercising sound judgment in difficult and sensitive situations.
� Communicate effectively with physicians and APP�s.
� Develop and maintain trustful relationships with a diverse group of providers.
� Maintain confidential information.
� Maintain positive work culture.
� Proficient ability to use a computer and electronic medical record.
� Able to manage time with patients to ensure patient schedule stays on time
� Must know that this visit has very strict requirements and visits will not differ significantly (joy must be found in the interaction with a variety of patients, not the variety of job functions)
� Understands preventive care guidelines (e.g. US Preventive Services Task Force, Medicare, etc.) and makes recommendations to patients accordingly
� Knowledgeable of community resources.
� Aware of scope of practice boundaries, seeking comfortable direction and assistance from appropriate resources.
WORKING CONDITIONS/PHYSICAL DEMANDS
� Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
� Constant lift up to 10 lbs.
� Constant talking, hearing, near vision, midrange vision, far vision.
� Frequent lift up to 25 lbs.
� Frequent standing, walking, sitting, reaching.
� Occasional lift up to 100 or more lbs.
� Occasional carrying, pushing, pulling, climbing, balancing.
� Occasional stooping, kneeling, crouching, squatting, twisting.
� Occasional handling, feeling, depth perception.
The Annual Wellness Visit Nurse supports Care Connect as a passionate advocate for patient needs and is committed to helping patients navigate the healthcare system, integral to our mission. Role is responsible for conducting the Medicare Annual Wellness Visit (AWV) with patients to assess current health status, identify potential risks, develop personalized prevention plans, and coordinating necessary follow-up care. This individual works under the supervision of the Director Practice Transformation.
Works in collaboration with the primary care provider and all members of the health care team. May also assist clinic staff with completion of other clinical tasks as needed. Assesses healthcare needs that require additional follow up by primary care provider and assists patients in scheduling appropriate follow-up.
Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation.
Responsibilities
Patient assessment:
� Conducts onsite and telehealth Medicare Annual Wellness visits with eligible adult primary care patients. Responsible for a full patient schedule.
� Taking detailed health histories, performing basic physical assessments (like vital signs, height, weight), and reviewing medication lists.
Health risk assessment:
� Utilizing standardized tools to identify potential health concerns based on patient demographics, lifestyle factors, medical and family history.
� Identifies health risks, promotes healthy lifestyles, and provides wellness education.
Preventive care planning:
� Develop a customized prevention plan focused on prevention and detection for early health problems.
� Perform pre-visit planning to ensure appropriate follow-up and documentation of preventive screeners including health maintenance items.
� Discussing and scheduling necessary preventive screenings (cancer screenings, immunizations) and discussing lifestyle modifications.
Patient education:
� Providing information on health conditions, disease prevention, healthy lifestyle choices, and medication adherence.
Care coordination:
� Identifying and referring patients to specialists or community resources as needed, coordinating follow-up appointments, and communicating findings to other healthcare providers
Documentation:
� Maintains confidentiality of patient information according to established practice policies and government regulations, such as HIPAA.
� Accurately recording patient information, assessments, care plans, and interventions in the electronic medical record
� Ensures that documentation and billing of services performed is sufficient to meet CMS guidelines, correct coding guidelines and other payer quality incentive program guidelines.
Miscellaneous:
� Attends conferences, in-service programs and continuing education activities to meet the organization�s expectations.
� Follows Standard Precautions using personal protective equipment as required.
� Other duties, as assigned.
Qualifications
EDUCATION/EXPERIENCE
� Nursing Degree (ADN, Diploma, BSN) from an accredited school of nursing.
� License to practice professional nursing (RN) in the State of Michigan. BLS required.
� Experience with EPIC strongly preferred.
� Thorough understanding of Medicare guidelines regarding AWVs preferred.
KNOWLEDGE/SKILLS/ABILITIES
� Strong working knowledge of hospital operations and healthcare environment.
� Excellent written/oral communication interpersonal and leadership skills.
� Proficient customer service skills, time management and organizational skills, and self-directed.
� Ability to make quality, independent decisions while exercising sound judgment in difficult and sensitive situations.
� Communicate effectively with physicians and APP�s.
� Develop and maintain trustful relationships with a diverse group of providers.
� Maintain confidential information.
� Maintain positive work culture.
� Proficient ability to use a computer and electronic medical record.
� Able to manage time with patients to ensure patient schedule stays on time
� Must know that this visit has very strict requirements and visits will not differ significantly (joy must be found in the interaction with a variety of patients, not the variety of job functions)
� Understands preventive care guidelines (e.g. US Preventive Services Task Force, Medicare, etc.) and makes recommendations to patients accordingly
� Knowledgeable of community resources.
� Aware of scope of practice boundaries, seeking comfortable direction and assistance from appropriate resources.
WORKING CONDITIONS/PHYSICAL DEMANDS
� Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
� Constant lift up to 10 lbs.
� Constant talking, hearing, near vision, midrange vision, far vision.
� Frequent lift up to 25 lbs.
� Frequent standing, walking, sitting, reaching.
� Occasional lift up to 100 or more lbs.
� Occasional carrying, pushing, pulling, climbing, balancing.
� Occasional stooping, kneeling, crouching, squatting, twisting.
� Occasional handling, feeling, depth perception.
