Annual Wellness Visit Nurse - Family Medicine-PBC

Marshall Health•Huntington, WV

About The Position

The Annual Wellness Visit Nurse conducts detailed health assessments, including reviewing medical histories, evaluating current health conditions, and identifying potential health risks. The nurse helps identify patients who may benefit from an integrated visit with care management or coordination services and provides education on preventive health practices, lifestyle modifications, and chronic disease management. The nurse supports patients in making progress toward their health goals and revises healthcare plans in collaboration with patients and the healthcare team. The role includes accurately and promptly documenting patient information, vital signs, health histories, and screening results in electronic medical records. The nurse collaborates with physicians, nurse practitioners, and other team members to develop and implement individualized care plans; coordinates referrals, follow-up appointments, screenings, and tests; and advocates for patients to help them achieve their maximum level of health. The nurse also works with the RN Quality Manager on quality metrics, care coordination, and enrollment and support of care management programs. All activities must comply with applicable laws, regulations, and organizational policy.

Responsibilities

Conduct detailed annual wellness health assessments, reviewing medical histories, evaluating current health conditions, and identifying potential health risks.
Help identify patients who may benefit from integrated visits with care management or coordination services.
Educate patients about preventive health practices, lifestyle modifications, chronic disease management, and their specific conditions and needs.
Provide ongoing support and evaluate progress toward stated health goals; revise healthcare plans in collaboration with patients and the healthcare team.
Document patient information, vital signs, health histories, and screening results accurately and in a timely manner in electronic medical records.
Assess risks based on patient data and recommend preventive care and follow-up actions.
Collaborate with physicians, nurse practitioners, and other healthcare team members to develop and implement individualized care plans.
Participate in regular team and organizational meetings.
Assist with orientation of new personnel related to quality improvement and population health.
Promote a collaborative atmosphere across the organization.
Collaborate with the RN Quality Manager to improve quality metrics and care coordination and to assist with enrollment in and support of care management programs.
Coordinate referrals, follow-up appointments, and additional screenings or tests as necessary.
Advocate for patients and help them obtain their maximum level of health.
Foster a supportive environment that encourages patients to take an active role in their health and wellness.
Ensure activities comply with applicable laws, regulations, and organizational policy.
Perform other duties as assigned or requested.