MSO ANNUAL WELLNESS VISIT (AWV) NURSE PRACTITIONER

NORTH EAST MEDICAL SERVICES•Burlingame, CA

1d•$81 - $111

About The Position

SUMMARY OF POSITION: The Annual Wellness Visit (AWV) Nurse Practitioner (NP) plays a critical role in improving patient outcomes through conducting comprehensive preventive care for Medicare patients. This includes early identification of high-risk conditions, creating personalized prevention plans, coordinating preventive services, and documenting visits to meet payer and regulatory requirements, including accurate capturing of Hierarchical Condition Categories (HCCs). The AWV NP is responsible for completing AWVs, including completing a detailed evaluation of the medical and social assessment of the patients, identifying health risks, reviewing medical history, screening for cognitive/functional impairment, and collaborating with primary care teams. The position requires strong assessment, clinical judgment, and team collaboration. The AWV NP must have excellent communication and facilitation skills. Ability to collaborate effectively within interdisciplinary teams, proficiency in Epic, detailed and accurate chart documentation, and familiarity with CMS guidelines are all essential requirements for the job. The position involves both in-office and remote/telehealth assessments; local travel may be required for in-home or on-site patient visits. This position will be an important component of the NEMS AWV Program.

Requirements

Active Nurse Practitioner (NP) license in California.
National certification as an NP (e.g., AANP, ANCC) appropriate to population focus (Family NP, Adult-Gerontology NP, or geriatric NP preferred).
Current Basic Life Support certification required
Demonstrate willingness to make decisions within NP's clinical scope of practice, exhibit sound, accurate, and ethical judgment.
Minimum of 1-2 years clinical experience (Previous experience in Medicare AWV, geriatric care, primary care, or chronic disease management is highly preferred).
Knowledge of Medicare Annual Wellness Visit requirements preferred.
Proficiency with Epic electronic health records and basic clinical documentation and billing workflows.
Ability to engage and work collaboratively with others, including patients, patient's families, clinical team members, organization leadership, and community resources.
Strong communication, teaching, and care coordination skills; ability to work with people from diverse backgrounds and experiences.
Time management and prioritization skills are vital.
Must be able to fluently speak, read, and write English.

Nice To Haves

Familiarity with preventive care quality metrics, care-gap closure initiatives, and population health programs is preferred.
Fluency in Chinese (Cantonese and Mandarin) preferred.
Fluency in other languages is an asset.

Responsibilities

Conduct Medicare Annual Wellness Visits (initial and subsequent) including a health risk assessment, medical/family/social history update, medication reconciliation, and review of functional status and cognitive risk.
Review preventive screening (e.g., depression screening, fall risk, cognitive screening) results and discuss appropriate follow-up or referrals.
Develop and document a personalized prevention plan (PPS) that lists recommended preventive services, screening schedules, and health promotion counseling.
Reconcile medications and review immunization status; order vaccines, labs, imaging, or specialty referrals as indicated.
Provide patient education on prevention, chronic disease self-management, lifestyle changes, advance care planning, and community resources.
Ensure AWV documentation meets Medicare and organizational documentation/billing requirements; enter visit data accurately in the EHR and use appropriate visit codes per clinic policy.
Coordinate care with primary care providers, specialists, case managers, social workers, and community services to close care gaps.
Track AWV-related quality metrics and participate in quality improvement efforts to increase AWV completion and preventive service adherence.
Maintain up-to-date knowledge of preventive care guidelines and Medicare AWV rules relevant to practice.
Support telehealth AWV workflows where applicable.
Performs other job duties as required by manager/supervisor.