Registered Nurse - Annual Wellness Visit (AWV

Choptank Community Health System, Inc..•Denton, MD

5d•$31 - $46•Hybrid

About The Position

The Medicare Annual Wellness Visit Registered Nurse (AWV Nurse) with Choptank Community Health (CCHS) is a critical part of the healthcare team and is responsible and accountable to patients. In this role, the AWV Nurse leads and conducts nurse-led Medicare Annual Wellness Visits (AWVs) to support preventive care, chronic disease management, and population health initiatives. The AWV Nurse focuses on health risk assessment, care planning, patient education, and care coordination to improve outcomes and close care gaps. Utilizing the nursing process, the AWV Nurse assesses and identifies patient health status, develops individualized prevention plans, and evaluates patient responses. The AWV Nurse maintains a safe, comfortable, and hazard-free environment for patients, visitors, and staff and exercises sound clinical judgment in all assigned responsibilities. This is a nonexempt, full-time position in pay grade 7 with the pay range of $31.41 - $45.55. The Medicare Annual Wellness Visit Registered Nurse reports directly to the Director of Quality & Population Health.

Requirements

Working knowledge of automated patient data systems.
Strong assessment and patient education skills, particularly in preventive care
Ability to complete comprehensive health risk assessments and care plans
Proficient in computer skills and documentation standards
Strong communication and care coordination skills
CPR certified within orientation period
Graduate of an accredited school of nursing.
Current licensure by the Maryland State Board of Nursing.
Minimum 1 year nursing experience preferred.
Working knowledge of ICD-10 and CPT coding related to preventive services.

Nice To Haves

Knowledge of Medicare Annual Wellness Visit requirements and documentation preferred
Preferred experience in primary care, population health, or care management
Experience with Medicare patients, preventive care or AWVs strongly preferred
Preferred experience in various medical settings to include primary care, adult acute care such as medical-surgical care or critical care

Responsibilities

Conduct nurse-led Medicare Annual Wellness Visits (AWVs) in alignment with CMS guidelines and CCHS procedures
Complete and document Health Risk Assessments (HRAs)
Obtain and review medical, surgical, family, and social history
Perform thorough medication reconciliation
Assess cognitive status, functional ability, fall risk, and safety concerns using evidence-based tools
Identify and address care gaps including screenings, immunizations, and preventive services
Develop and document individualized Personalized Prevention Plans (PPPS)
Provide patient-centered education on disease prevention and health maintenance
Collects health status data relevant to the patient’s presenting problem or visit in accordance with infection control policies and protocols in a continuous, systemic, and complete manner.
Consistently and accurately documents in the Electronic Health Record according to established procedures.
Establishes appropriate priorities in planning and implementing patient care.
Protects patients by adhering to infection control policies and protocols, medication administration, and storage procedures.
Assists in implementing the plan of care as requested by the Clinician including medication reconciliation, calculating doses of medications, injections, EKG’s, nebulizer treatments, pain screening, collecting and preparing laboratory specimens, performing dressing changes and wound care, and performing CLIA waived tests.
Collaborates with other health team members during the entire patient visit process including other nurses, phlebotomist, clinician, medical assistant, referral coordinator, patient outreach specialist, and PSS.
Focus on preventive care education including: Chronic disease prevention and management (diabetes, hypertension, etc.), Nutrition, physical activity, and lifestyle modification, Medication adherence and safety
Deliver tailored patient education using evidence-based materials and tools
Promote patient engagement and adherence to care plans
Support value-based care initiatives and population health strategies
Encourage completion of recommended preventive screenings
Work collaboratively with interdisciplinary teams including providers, medical assistants, care coordinators, staff nurses, and outreach staff
Identify high-risk patients and escalate care needs appropriately
Track and follow up on care gaps and preventive services
Participate in team huddles and population health initiatives
Documents all AWVs, patient interactions, and care coordination activities
Properly documents and completes ICD-10 and CPT coding for services administered during the patient visit.
Reviews patient’s electronic health record for last office visit, lab work, and CDS/PDMP compliance if necessary.
Appropriately documents when a patient picks up patient assistance or sample medications within the patient’s electronic health record.
Participate in quality improvement efforts related to preventive care and AWVs across all seven health centers.
Support performance metrics related to Medicare wellness visits and care gap closure
Identify opportunities to improve workflows and patient outcomes
Maintains a safe and hygienic environment for patients.
Cleans and sterilizes exam room after every patient visit in addition to removing all patient specimens.
Properly dons and doffs PPE as required for each type of patient encounter.
At the end of each day, the nurse will work with the medical assistants to ensure proper disinfection of every exam room and work area including lab.
Follows protocol for distinction of clean and dirty areas within the lab.
Communicates with members of the healthcare team to address patient’s questions and/or concerns.
Consistently identifies patients at risk and communicates with clinician on emergent patient needs.
Consistently displays professionalism and respect during interaction with CCHS customers, staff, and clinicians.
Assist with additional nurse visits or population health initiatives as needed
Support clinic workflows and team-based care delivery
Travel to other sites as needed
Attend meetings and trainings as required
Maintain professionalism and commitment to patient-centered care
Regular, reliable attendance is a requirement of this job.