Registered Nurse - Annual Wellness Visit (AWV

Job Description

Job Description

Medicare Annual Wellness Visit (AWV) Registered Nurse

Job Summary : The Medicare Annual Wellness Visit Registered Nurse (AWV Nurse) with Choptank Community Health (CCHS) is a critical part of the healthcare team and is responsible and accountable to patients. In this role, the AWV Nurse leads and conducts nurse-led Medicare Annual Wellness Visits (AWVs) to support preventive care, chronic disease management, and population health initiatives. The AWV Nurse focuses on health risk assessment, care planning, patient education, and care coordination to improve outcomes and close care gaps. Utilizing the nursing process, the AWV Nurse assesses and identifies patient health status, develops individualized prevention plans, and evaluates patient responses. The AWV Nurse maintains a safe, comfortable, and hazard-free environment for patients, visitors, and staff and exercises sound clinical judgment in all assigned responsibilities. This is a nonexempt, full-time position in pay grade 7 with the pay range of $31.41 - $45.55. The Medicare Annual Wellness Visit Registered Nurse reports directly to the Director of Quality & Population Health.

Required Skills/Abilities:

• Working knowledge of automated patient data systems.
• Strong assessment and patient education skills, particularly in preventive care
• Knowledge of Medicare Annual Wellness Visit requirements and documentation preferred
• Ability to complete comprehensive health risk assessments and care plans
• Proficient in computer skills and documentation standards
• Strong communication and care coordination skills
• CPR certified within orientation period
• Working knowledge of ICD-10 and CPT coding related to preventive services.

Education and Experience:

• Graduate of an accredited school of nursing.
• Current licensure by the Maryland State Board of Nursing.
• Minimum 1 year nursing experience preferred.
• Preferred experience in primary care, population health, or care management
• Experience with Medicare patients, preventive care or AWVs strongly preferred
• Preferred experience in various medical settings to include primary care, adult acute care such as medical-surgical care or critical care

Working Conditions and Physical Requirements:

• General office environment
• Occasional travel
• Frequent exposure to workplace conditions includes bending, climbing stairs, walking, kneeling, and reaching.
• Includes fine and gross motor skills, lifting less than 20 pounds, and vision.
• Occasional exposure to workplace conditions includes airborne pathogens, blood borne pathogens and cleaning agents.

Standards of Behavior:

• Commitment To Service
• Respect
• Quality
• Teamwork
• Patient Focus
• Integrity
• Accountability
• Caring & Compassion
• Professionalism
• Listening & Responding
• Safety
• AIDET

Job Related Competencies:

• Empathetic Outlook- The ability to perceive and understand the feelings and attitudes of others; the ability to place oneself “in the shoes” of another and to view a situation from their perspective.
• Attention to Detail - The ability to process detailed information effectively and consistently.
• Problem Solving- Identifies and analyzes problems weighing the relevance and accuracy of available information. Generates and evaluates alternative solutions and makes effective and timely decisions.
• Communicates Effectively- Developing and delivering multi-mode communication that convey a clear understanding of the unique needs of different audiences.
• Values And Ethics - Serving with integrity and respect in personal and organizational practices. Ensuring decisions and transactions are transparent and fair.
• Time Management- The ability to effectively manage one’s time and resources to ensure that work is completed efficiently.

Commitment to Community:

Choptank Community Health System (CCHS) is committed to creating a safe and open healthcare environment that improves health outcomes and values and respects the unique experiences and perspectives of both patients and staff by:

• Prioritizing access for all individuals;

• Offering ongoing training for staff to promote health awareness, preventive measures and early detection for the varied patient population on the Eastern Shore;

• Actively engaging with patients, families and staff;

• Fostering a workplace culture in which everyone is treated with dignity.

Duties/Responsibilities:

• Medicare Annual Wellness Visits

• Conduct nurse-led Medicare Annual Wellness Visits (AWVs) in alignment with CMS guidelines and CCHS procedures
• Complete and document Health Risk Assessments (HRAs)
• Obtain and review medical, surgical, family, and social history
• Perform thorough medication reconciliation
• Assess cognitive status, functional ability, fall risk, and safety concerns using evidence-based tools
• Identify and address care gaps including screenings, immunizations, and preventive services
• Develop and document individualized Personalized Prevention Plans (PPPS)
• Provide patient-centered education on disease prevention and health maintenance

• Patient Interaction and Collaboration
  • Collects health status data relevant to the patient’s presenting problem or visit in accordance with infection control policies and protocols in a continuous, systemic, and complete manner.
  • Consistently and accurately documents in the Electronic Health Record according to established procedures.
  • Establishes appropriate priorities in planning and implementing patient care.
  • Protects patients by adhering to infection control policies and protocols, medication administration, and storage procedures.
  • Assists in implementing the plan of care as requested by the Clinician including medication reconciliation, calculating doses of medications, injections, EKG’s, nebulizer treatments, pain screening, collecting and preparing laboratory specimens, performing dressing changes and wound care, and performing CLIA waived tests.
  • Collaborates with other health team members during the entire patient visit process including other nurses, phlebotomist, clinician, medical assistant, referral coordinator, patient outreach specialist, and PSS.
• Planning, Implementation of Patient Care and Patient Education

• Focus on preventive care education including:

• Chronic disease prevention and management (diabetes, hypertension, etc.)
• Nutrition, physical activity, and lifestyle modification
• Medication adherence and safety

• Deliver tailored patient education using evidence-based materials and tools
• Promote patient engagement and adherence to care plans
• Support value-based care initiatives and population health strategies
• Encourage completion of recommended preventive screenings

• Care Coordination & Population Health
  • Work collaboratively with interdisciplinary teams including providers, medical assistants, care coordinators, staff nurses, and outreach staff
  • Identify high-risk patients and escalate care needs appropriately
  • Track and follow up on care gaps and preventive services
  • Participate in team huddles and population health initiatives
• Documentation within the Electronic Health Record
  • Documents all AWVs, patient interactions, and care coordination activities
  • Properly documents and completes ICD-10 and CPT coding for services administered during the patient visit.
  • Reviews patient’s electronic health record for last office visit, lab work, and CDS/PDMP compliance if necessary.
  • Appropriately documents when a patient picks up patient assistance or sample medications within the patient’s electronic health record.
• Quality Improvement
  • Participate in quality improvement efforts related to preventive care and AWVs across all seven health centers.
  • Support performance metrics related to Medicare wellness visits and care gap closure
  • Identify opportunities to improve workflows and patient outcomes
• Maintains a safe and hygienic environment for patients.
  • Cleans and sterilizes exam room after every patient visit in addition to removing all patient specimens.
  • Properly dons and doffs PPE as required for each type of patient encounter.
  • At the end of each day, the nurse will work with the medical assistants to ensure proper disinfection of every exam room and work area including lab.
  • Follows protocol for distinction of clean and dirty areas within the lab.
• Effectively Communicates Within the Center
  • Communicates with members of the healthcare team to address patient’s questions and/or concerns.
  • Consistently identifies patients at risk and communicates with clinician on emergent patient needs.
  • Consistently displays professionalism and respect during interaction with CCHS customers, staff, and clinicians.

• Performs Other Duties as Required
  • Assist with additional nurse visits or population health initiatives as needed
  • Support clinic workflows and team-based care delivery
  • Travel to other sites as needed
  • Attend meetings and trainings as required
  • Maintain professionalism and commitment to patient-centered care
• Regular, reliable attendance is a requirement of this job.

Benefits:

• Tuition and education assistance
• Certification scholarships available
• Paid holidays (9)
• Flexible paid time off and vacation scheduling
• 403(b)
• 403(b) matching
• Employee assistance program
• Flexible spending account
• Health insurance
• Dental insurance
• Vision coverage
• Life insurance
• Referral program
• Employee wellness program
• Discretionary Bonuses

Choptank Community Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital or family status, veteran status, sexual orientation, gender identity or expression, genetic information, political affiliation, arrest record, or any other characteristic protected by applicable federal, state, or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.