Wellness Nurse

Summary

The Wellness RN supports the primary care team by implementing the Medicare Annual Wellness Visit (AWV) for all eligible patients according to Medicare guidelines, supporting patient self-management and education, and ensuring outcome quality metrics are met. Implementation of the Medicare AWV process includes pre-visit review of the patient's electronic health data to determine preventative screening eligibility and gaps in care. In collaboration with a physician or mid-level provider, the Wellness RN will assess the physical, emotional, health safety, and community resource needs of the patient and refer to appropriate health services.

The qualified candidate must have a passion for helping patients prevent and/or control disease by encouraging healthy lifestyle choices and adherence to health screenings. This individual will be working in a team environment supporting providers and patients in a clinic setting.

• Directly meets with patients to complete “Welcome to Medicare Visit” and the Medicare AWV and fulfill the Medicare requirements to bill.
• Obtain the following measurements:
  • Height, weight, body mass index (or waist circumference, if appropriate)
  • Blood pressure
  • Other routine measurements as deemed appropriate based on medical and family history.
• Develops an efficient process for AWV, to include: AWV identification, communication, scheduling and follow‑up through collaboration with Medical Providers and office staff.
• Administer/review Health Risk Assessment (HRA) including:
  Self‑assessment of health status:
  Psychosocial risks;
  Behavioral risks;
  Activities of Daily Living (ADLs), including, but not limited to dressing, bathing, and walking; and instrumental ADLs.
• Works with Payer Relations to identify eligible Medicare patients for AWVs (Welcome, Initial and/or Subsequent) and completes the AWV according to Medicare best practice guidelines.
• Ensures that AWVs are coded accurately for compliance and financial opportunity purposes.
• Provides age‑based, cultural and language appropriate patient education.
• Encourages and facilitates patient self‑management of disease, behavior modification interventions, and home monitoring within the scope of an AWV.
• Oversees implementation, sustainability and process improvement for the AWVs including EHR documentation, auditing for quality metrics and financial reimbursement, and providing ongoing education for providers, office staff, and coders on Medicare updates.
• Utilizes and documents appropriate patent referrals including preventive screening, though collaboration with Care Coordinators, Care Manager, and other Care Team members.
• Promotes clear communication amongst the care team.
• Facilitates the reconciliation process of patient medication.
• Works with assigned practices as appropriate and agreed upon to engage patients which may include but not limited to:
  • Directly engaging patients to ensure screening and other required preventative tests and appointments are completed.
  • Engaging patients through mailings, phone calls or other methods and working with practice to build a process to engage patients going forward.
  • Working with laboratories and other vendors as required to collect and enter patient results in the EHR.
• Required to attend meetings as necessary.
• Demonstrates knowledge of performance improvement by participating in collecting, compiling, and analyzing patient data.
• Communicates specific pieces of the plan of care to appropriate care team members.

• Perform AWVs.
• Assess chronic conditions and preventative care.
• Develop resources for training other wellness nurses.
• Explain processes and forms.
• Obtain health history through interviews.
• Educate patients regarding health promotion/illness prevention.
• Comply with all required elements of the Medical Annual Wellness.
• Understands and adheres to regulations for FQHCs and Primary Care Centers. Maintains a comprehensive working knowledge of community resources, payer requirements, and network services for target populations.
• Understands population health and works collaboratively with the health care team to promote health and wellness.
• Develops a strong knowledge of our…