Annual Wellness Visit Clinical Support Specialist - Marshall Internal Medicine

Marshall Health•Huntington, WV

2d•Onsite

About The Position

The RN/LPN – Annual Wellness Visit Clinical Support Specialist is responsible for conducting pre-visit outreach to patients scheduled for Annual Wellness Visits (AWVs). This role involves reviewing upcoming schedules, contacting patients by telephone to complete standardized questionnaires and health risk assessments, reviewing medical records, identifying missing preventive care information, and preparing concise clinical information for the provider. The specialist will also provide patient education, escalate clinical concerns, participate in workflow and quality improvement initiatives, and ensure accurate and timely documentation in the electronic medical record while maintaining patient confidentiality.

Requirements

RN/LPN license
Completion of standardized AWV pre-visit questionnaires and required health risk assessment components within the scope of licensure and organizational protocols.
Ability to obtain and document information related to: Activities of daily living and instrumental activities of daily living, Fall risk and safety concerns, Cognitive and functional status, Depression and other approved screening assessments, Social determinants of health, as applicable, Medication use and medication-related concerns, Preventive health services and screening history, Immunization status, Advance care planning, when applicable, Health behaviors and lifestyle factors, and Other information required to support completion of the AWV.
Ability to review the patient's medical record before completing the telephone questionnaire when appropriate.
Ability to identify missing or outdated preventive care information.
Ability to reconcile or update information within the RN/LPN's authorized scope.
Ability to identify potential gaps in preventive services, including screenings, immunizations, laboratory testing, or other recommended services.
Ability to ensure relevant information is accurately entered into the electronic medical record.
Ability to prepare concise clinical information for the provider to review during the AWV.
Ability to follow established workflows for routing clinical questions, abnormal screening responses, or other concerns to the appropriate provider or clinical team member.
Ability to provide patients with clear instructions regarding the purpose and process of the AWV.
Ability to educate patients regarding preparation for the visit, including bringing medication information, advance directive documentation, or other requested information.
Ability to reinforce preventive health recommendations within the individual's scope of practice and established protocols.
Effective telephone communication skills to establish rapport with patients and encourage completion of the pre-visit process.
Ability to recognize barriers to care and communicate identified needs to the appropriate clinical or administrative team.
Ability to recognize and appropriately escalate clinical concerns identified during the pre-visit telephone encounter.
Ability to immediately communicate urgent or potentially emergent concerns according to departmental protocols.
Ability to route abnormal screening results or patient-reported symptoms to the appropriate RN, APP, physician, or other designated clinician.
Understanding of limitations: Do not independently diagnose, treat, or provide clinical recommendations outside the individual's scope of practice, established protocols, or delegated authority.
Ability to document all clinical concerns and actions taken in accordance with organizational standards.
Ability to maintain a consistent and timely pre-AWV outreach workflow.
Ability to coordinate with scheduling staff to identify cancellations, rescheduled appointments, and patients requiring additional outreach.
Ability to re-attempt contact with patients who cannot initially be reached according to established outreach protocols.
Ability to document unsuccessful outreach attempts accurately.
Ability to identify recurring barriers or inefficiencies in the AWV process and communicate recommendations for improvement.
Willingness to participate in departmental quality improvement initiatives related to preventive care, AWV completion, patient access, documentation accuracy, and clinical workflow.
Willingness to assist in monitoring AWV-related performance metrics as assigned.
Ability to document telephone encounters accurately, timely, and completely.
Ability to enter questionnaire responses into the appropriate sections of the electronic medical record.
Ability to maintain appropriate documentation of outreach attempts.
Ability to clearly identify information requiring provider follow-up.
Commitment to maintaining patient confidentiality and complying with HIPAA and organizational privacy and security requirements.
Ensuring documentation supports appropriate clinical communication and continuity of care.
Expected to complete assigned pre-AWV outreach within established timeframes.
Expected to maintain a high level of accuracy when collecting and entering patient information.
Expected to maximize successful patient contact and questionnaire completion.
Expected to minimize incomplete or duplicate AWV documentation.
Expected to identify and appropriately escalate clinical concerns.
Expected to maintain professional and compassionate communication with patients.
Expected to support efficient provider workflows by ensuring information is available before the AWV.
Expected to consistently follow established AWV protocols and scope-of-practice requirements.

Responsibilities

Review upcoming AWV schedules and identify patients requiring pre-visit questionnaire completion.
Contact patients by telephone sufficiently in advance of their scheduled AWV.
Explain the purpose of the pre-visit questionnaire and obtain patient cooperation and accurate responses.
Complete standardized AWV pre-visit questionnaires and required health risk assessment components within the scope of licensure and organizational protocols.
Obtain and document information related to: Activities of daily living and instrumental activities of daily living, Fall risk and safety concerns, Cognitive and functional status, Depression and other approved screening assessments, Social determinants of health, as applicable, Medication use and medication-related concerns, Preventive health services and screening history, Immunization status, Advance care planning, when applicable, Health behaviors and lifestyle factors, and Other information required to support completion of the AWV.
Review the patient's medical record before completing the telephone questionnaire when appropriate.
Identify missing or outdated preventive care information.
Reconcile or update information within the RN/LPN's authorized scope.
Identify potential gaps in preventive services, including screenings, immunizations, laboratory testing, or other recommended services.
Ensure relevant information is accurately entered into the electronic medical record.
Prepare concise clinical information for the provider to review during the AWV.
Follow established workflows for routing clinical questions, abnormal screening responses, or other concerns to the appropriate provider or clinical team member.
Provide patients with clear instructions regarding the purpose and process of the AWV.
Educate patients regarding preparation for the visit, including bringing medication information, advance directive documentation, or other requested information.
Reinforce preventive health recommendations within the individual's scope of practice and established protocols.
Use effective telephone communication skills to establish rapport with patients and encourage completion of the pre-visit process.
Recognize barriers to care and communicate identified needs to the appropriate clinical or administrative team.
Recognize and appropriately escalate clinical concerns identified during the pre-visit telephone encounter.
Immediately communicate urgent or potentially emergent concerns according to departmental protocols.
Route abnormal screening results or patient-reported symptoms to the appropriate RN, APP, physician, or other designated clinician.
Do not independently diagnose, treat, or provide clinical recommendations outside the individual's scope of practice, established protocols, or delegated authority.
Document all clinical concerns and actions taken in accordance with organizational standards.
Maintain a consistent and timely pre-AWV outreach workflow.
Coordinate with scheduling staff to identify cancellations, rescheduled appointments, and patients requiring additional outreach.
Re-attempt contact with patients who cannot initially be reached according to established outreach protocols.
Document unsuccessful outreach attempts accurately.
Identify recurring barriers or inefficiencies in the AWV process and communicate recommendations for improvement.
Participate in departmental quality improvement initiatives related to preventive care, AWV completion, patient access, documentation accuracy, and clinical workflow.
Assist in monitoring AWV-related performance metrics as assigned.
Document telephone encounters accurately, timely, and completely.
Enter questionnaire responses into the appropriate sections of the electronic medical record.
Maintain appropriate documentation of outreach attempts.
Clearly identify information requiring provider follow-up.
Maintain patient confidentiality and comply with HIPAA and organizational privacy and security requirements.
Ensure documentation supports appropriate clinical communication and continuity of care.