RN / LPN ANNUAL WELLNESS VISIT - SCC POPULATION HEALTH / ACO

Job Description

Job Description

Job Title:

RN / LPN – Population Health / ACO Annual Wellness Visit Nurse

Population Health / ACO

Full Time

Provides nursing care within the Population Health / ACO program, focusing on Annual Wellness Visits (AWVs) for Medicare and Medicare Advantage patients. Acts as patient advocate, supports preventive care initiatives, and facilitates communication between patients, providers, and the interdisciplinary team to improve outcomes and close care gaps.

• Current RN license by the Mississippi Board of Nursing or

• Current LPN license by the Mississippi Board of Nursing

• Minimum of two (2) years clinical nursing experience

• Must be able to read, write, and understand verbal and written communication

• Strong organizational, communication, and time management skills

• BLS or ACLS certification.

• Experience in population health, primary care, or ACO environment

• Familiarity with Medicare Annual Wellness Visit requirements and quality metrics

• Experience with electronic health records (Epic preferred)

• Certification in Population Health or Case Management preferred

• Conduct Annual Wellness Visits including health risk assessments and screenings

• Identify eligible Medicare patients and coordinate AWV completion

• Develop individualized care plans based on patient needs and clinical guidelines

• Review and address care gaps and assist with closing quality measures

• Document all patient interactions accurately in the electronic health record

• Educate patients on disease prevention and self-management strategies

• Collaborate with physicians and care team members for coordinated care

• Monitor patient populations and support outreach initiatives

• Assist with patient messages, prescription refills, and other clinical tasks as needed

• Maintain compliance with ACO, CMS, and organizational standards

• Represent the organization professionally

• Maintain patient, team member, and employer confidentiality (HIPAA compliance)

• Promote safety, infection control, and quality improvement

• Maintain competency and adhere to policies

• Demonstrate teamwork, communication, and reliability

• Ability to sit, stand, and/or walk for extended periods

• Frequent computer use and documentation

• Occasional bending, reaching, and movement between work areas

• Manual dexterity for clinical tasks and computer use; adequate vision, hearing, and speech

All candidates must be able to perform the essential functions of this position. The Americans with Disabilities Act (ADA) requires that reasonable accommodations be made for qualified individuals to perform the essential functions of the position.

South Central Regional Medical Center is an equal opportunity employer and does not discriminate based on race, color, religion, sex, gender, national origin, age, disability, or genetic information.