Wellness Visit Coordinator

Overview

Supervisory-Specific Performance Expectations, Duties, and Responsibilities: N/A

Position-Specific Performance Expectations, Duties, and Responsibilities:

• Annual Wellness Visits (AWV):
  Completes pre-visit planning and identifies patient needs for age-appropriate screenings and immunizations, in collaboration with MRH’s family practice providers. Provides education to patients about their conditions within the scope of practice. Updates health records utilizing the tools in the electronic health record. Documents patient visits in electronic health records in a timely manner.
• Value-Based Care (VBC): Supports data-driven VBC initiatives for Medicare, Medicare Advantage, Medicaid, and commercial insurance plan beneficiaries. Includes direct patient outreach for medication adherence and collaboration with Primary Care Physicians (PCP) and clinic staff to monitor and follow up with high-risk and impactable patients identified through claims data as needing wellness visits, follow-up appointments, lab work, and other care.
• Lifeline
  :
  Primary point of contact for enrollment, equipment set-up, and technical support of personal emergency response system (PERS) devices. Reviews monthly invoices to ensure correct billing.
• Assists MRH family practice providers with population health initiatives for specific diagnoses, i.e., diabetes, CHF, COPD, hypertension, etc.
• Team-Based care (TBC). Provides relevant health care information to Family Practice Providers to help assess if patients would benefit from Chronic Care Management (CCM); enter Referrals on behalf of Providers for CCM, Patient Navigation, and/or social Care Coordination for ongoing support, as applicable. Has an existing understanding of Medicare Annual Wellness Visits (MAWV) and Chronic Care Management (CCM) services, OR has an interest and ability to learn about MAWV and CCM;
  
  ability to explain the purpose and value of MAWV and CCM to patients.
• Performs other duties as assigned.
• Estimated time allocation: AWV 80%; VBC 10%;
  Lifeline 10%.

General Requirements

• Maintains accurate documentation of patient encounters and ensures timely reporting according to department and organizational standards and requirements.
• Attends recurring staff meetings and trainings as assigned.
• Participates in the development of processes to achieve improved health outcomes and programmatic efficiencies.
• Meets patient onsite at the clinic/hospital, public spaces, homes, or other appropriate locations to assess needs and provide support.
• Communicated professionally and effectively with patients, community members, professional partners, grantors, and in other professional settings.
• Possesses critical thinking and problem-solving skills, uses data to make informed decisions, and is both self-directed as well as a collaborative team member.
• Occasional weekend work, and other duties as assigned.

Organization-Specific Performance Expectations, Duties, and Responsibilities:

• Demonstrates 100% commitment to performance in accordance with the CHOICE values of MRH and represents the organization in a positive and professional manner.
• Establishes and maintains effective verbal and written communication and good working relationships with all patients, staff, and vendors.
• Adheres to MRH attire/dress code per policies and procedures.
• Utilizes initiative; strives to maintain a steady level of productivity; self-motivated; and manages activity and time.
• Completes annual education, training, in-service, and licensure/certification requirements; and attends departmental and organizational staff meetings or reads meeting minutes.
• Maintains patient confidentiality at all times.
• Reports to work on time as scheduled; completes work within designated time frames.
• Actively participates in departmental and organizational performance improvement and continuous quality improvement activities.
• Strives to uphold regulatory requirements to ensure continual compliance with departmental, hospital, state, and federal regulations and policies.
• Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, the public, and staff.

Qualifications:

• Must be at…