RN Wellness

The Annual Wellness Visit nurse works in collaboration with the primary care provider and all members of the health care team. Primary responsibilities include outreach to Medicare patients appropriate for Annual Wellness Visits (AWV) and execution of guided processes to complete the AWV. May also assist clinic staff with completion of other clinical tasks as needed. Assesses healthcare needs that require additional follow up by primary care provider and assists patients in scheduling appropriate follow-up. Knowledgeable of community resources and assists patients in connecting with those resources. Serves as patient advocate and assists in identification and improvement of service delivery. This position requires expertise in the nursing process, using critical thinking skills to plan and coordinate care. Responsible and accountable for direct and indirect patient care for designated patient populations.

Job Duties

• Excellent communication skills.

• Review clinic schedule and identifies patients appropriate and due for Medicare AWV.

• Work collaboratively with clinical teams to accomplish AWV in an efficient manner for patient and team.

• Follow AWV protocols and standing orders including completion of preventive services that may result from AWV.

• Acts as patient advocate.

• Develop and shares knowledge of AWV eligibility and documentation requirements.

• Develop knowledge of Medicare preventive services and clinical guideline recommendations for those services.

• Address open quality gaps with patients and works collaboratively with patient towards closure of those gaps.

• Appropriately documents within the electronic record to satisfy closed quality gaps.

• May assist with other clinical duties such as prior authorizations, patient messages, prescription refills.

• Utilize appropriate protocols and standing orders in delivering patient care

• Demonstrates excellent written, and communication skills, positive relationship building skills, and critical analysis skills.

• Maintains required documentation for all clinical activities.

Qualifications and Education

• Current Michigan Registered Nurse, Nurse Practitioner, or Physician Assistant License

• Three years of experience with adult medicine in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, risk assessment, and patient education
• Critical thinking skills and ability to manage complex clinical issues utilizing assessment skills and protocols
• Excellent assessment / triage skills with the ability to implement evidence base interventions and protocols
• Demonstrates excellent communication--both verbal and written
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
• Time management, priority setting, work delegation and work organization.
• General computer knowledge and capability to use computer.