Annual Wellness Visit (AWV) Registered Nurse Hybrid

Job Title: Annual Wellness Visit (AWV) Registered Nurse

Department: Population Health

FLSA Status : Non-exempt

About us

Physicians East a team of skilled healthcare professionals united to meet the challenge of delivering quality cost-efficient comprehensive healthcare to the people of Eastern North Carolina.

Location & commitments

Part Time role - Hybrid Work Model - based at our Arlington location Hours are flexible. Option to work partly from home in HIPAA appropriate setting.

Supervision Received: Reports to Population Health supervisor.

Supervision Exercised: None.

Typical Physical Demands: Requires full range of body motion manual and dexterity and eye-hand coordination. Requires normal visual acuity and hearing. Requires sitting for extended periods.

Typical Working Conditions:

Office environment or home office setting.

About the role

The Annual Wellness Visit (AWV) Registered Nurse is responsible for coordinating and conducting Medicare Annual Wellness Visits in accordance with CMS guidelines. The RN works collaboratively with primary care providers and the interdisciplinary care team to identify preventive care needs close quality gaps promote chronic disease management and improve patient outcomes while ensuring accurate documentation within the electronic health record (EHR)

Responsibilities : (This list may not include all the duties assigned.)

Annual Wellness Visits

• Conduct Medicare Initial Preventive Physical Exams (IPPE) Initial Annual Wellness Visits and Subsequent Annual Wellness Visits according to CMS requirements.
• Obtain and document comprehensive patient histories including:

• Medical and surgical history
• Family history
• Social history
• Current medications and allergies

• Perform and document:

• Health Risk Assessment (HRA)
• Functional status assessment
• Fall risk screening
• Depression screening (PHQ-2/PHQ-9 as appropriate)
• Cognitive assessment
• Safety assessment
• Advance care planning discussions

• Record vital signs and other required clinical measurements.
• Develop and update each patients Personalized Prevention Plan.

Quality & Preventive Care

• Identify and close preventive care gaps.
• Review immunization status and recommend appropriate vaccines.
• Ensure recommended screenings are ordered or scheduled including:

• Mammograms
• Colon cancer screening
• Bone density testing
• Lung cancer screening
• Abdominal aortic aneurysm screening
• Hepatitis C screening

• Coordinate referrals for preventive services when appropriate.

Care Coordination

• Collaborate with physicians nurse practitioners physician assistants care managers referral coordinators and ancillary departments.
• Identify patients who may benefit from Chronic Care Management (CCM) or other care management programs.
• Coordinate follow-up appointments for medical conditions identified during the wellness visit.
• Communicate abnormal findings to the patients provider.

Documentation & Compliance

• Complete all documentation accurately and timely within the EHR.
• Ensure compliance with CMS Medicare payer and organizational documentation standards.
• Assist with quality reporting initiatives including MIPS ACO HEDIS and other value-based care programs.
• Support accurate coding by documenting required components of the Annual Wellness Visit.

Patient Education

• Educate patients regarding:

• Preventive health recommendations
• Lifestyle modifications
• Nutrition and exercise
• Tobacco cessation
• Fall prevention
• Medication adherence
• Advance directives

Population Health

• Identify eligible Medicare beneficiaries for Annual Wellness Visits.
• Participate in outreach initiatives to improve AWV completion rates.
• Monitor quality dashboards and assist in achieving organizational quality goals.

Candidate requirements

• Graduate of an accredited Registered Nursing program.
• Current RN license in the applicable state.
• BLS certification required.

• Experience with value-based care initiatives.

Affirmative Action/EEO statement

Physicians East P.A. is an equal opportunity employer and will not discriminate against any applicant or employee on the basis of age race color ethnicity religion creed sex (including gender pregnancy sexual orientation and gender identity which includes status as a transgender individual) national origin or ancestry citizenship past current or prospective service in the uniformed services genetic information (including family medical history) physical or mental disability or other legally protected status. Reasonable accommodation will be made for persons with disabilities during the application process and/or at the time of employment. Requests for accommodation should be made to the Human Resources Department as early as possible in the application/employment process. Contact HR Office at

Disclaimer

Please note this job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of the employee for this job. Duties responsibilities and activities may change at any time with or without notice.

Required Experience:

IC