Annual Wellness Visit Care Coordinator

SUMMARY

Montage Medical Group's Collaborative Care Services (CCS) department supports patients and care teams in navigating the complex healthcare system with compassion, kindness, and reliability. We are trusted in our knowledge and follow through. We meet our patients where they are and advocate for their needs. Our team consists of Registered Nurse Care Managers, Licensed Vocational Nurse (LVN) Clinical Care Coordinators, Social Workers, Pharmacy Technicians and Care Coordinators.

The CCS Clinic-Based AWV Coordinator is embedded within primary care clinics to identify, prepare, and facilitate completion of Annual Wellness Visits for eligible patients. This role partners closely with clinic staff and the centralized CCS team to conduct proactive outreach, perform pre-visit planning, close preventive care gaps, and coordinate same-day or alternative AWV opportunities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities Include:
• Reviews clinic schedules to identify patients presenting for non-AWV visit types who are eligible for an AWV and coordinates same-day or alternative-resource AWV completion while the patient is on site.
• Performs comprehensive pre-visit planning for scheduled AWVs, including completion of required AWV questionnaires telephonically when not completed by the patient via MyChart at least two days prior to the visit.
• Tracks and follows up on incomplete AWVs or missed appointments to improve completion rates.
• Proactively contacts eligible patients by phone and other approved outreach methods to schedule Annual Wellness Visits (AWVs).
• Promotes MyChart enrollment and electronic questionnaire completion to support efficient workflows.
• Utilizes standardized clinical protocols and standing orders to initiate or pend orders for due or overdue preventive screenings and tests in preparation for AWVs.
• Partners with primary care clinic staff, CCS team members, and providers to coordinate patient care and ensure continuity across the care continuum.
• Accurately documents AWV-related activities, outreach efforts, and completed elements within the electronic health record according to established workflows.
• Participates in AWV-related pilots or initiatives aimed at improving access, efficiency, or patient experience.
• Proactively generates, tests, and refines creative solutions to improve processes and outcomes.
• Maintains strict compliance with organizational policies related to patient confidentiality, HIPAA, and administrative standards.
• Actively participates in CCS, clinic, and interdisciplinary team meetings as assigned.
• Adheres to departmental attendance, punctuality, and professional conduct standards.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibilities.

MONTAGE VALUES

Employees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.

EDUCATION:
• Required: High school diploma or general education degree ("GED")
• Preferred: Certificate or Associates Degree in Medical Assisting is highly desirable

EXPERIENCE:
• Preferred: 1 or more years of experience working in a primary care setting is highly desirable

SKILLS AND ABILITIES:
• Ability to collaborate with stakeholders to co-create and strengthen the AWV program and workflows.
• Ability to appropriately interact with patients, families, staff and others.
• Strong interpersonal skills to handle sensitive situations and confidential information.
• Must respond sympathetically and maturely to patient needs.
• Detail oriented and well organized.
• Skill in health information management by appropriately charting patient data.
• Strong computer skills with strong capabilities in MS Office Suite i.e. Outlook, Word, Power Point and Excel
• Ability to function effectively in a fluid, dynamic, and rapidly changing environment.
• Ability to articulate clearly and concisely both verbally and in writing.
• Ability to self-direct in keeping with departmental and organizational priorities.
• Ability to work autonomously and be directly accountable for assignments.
• Ability to work effectively as a team member with physicians and other staff.
• Ability to apply attention to detail and accuracy.
• Bilingual English/Spanish is preferred.
• Knowledge of Monterey County community resources is preferred.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand; walk; climb or balance; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.