Population Health AWV Care Manager

Population Health Annual Wellness Visit Nurse

JOB DESCRIPTION

The Annual Wellness Visit nurse works in collaboration with the primary care provider and all members of the health care team. Primary responsibilities include identification of Medicare and Medicare Advantage patients appropriate for Annual Wellness Visits (AWV) and execution of guided processes to complete the AWV. 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.

Position Requirements:

Current licensure as a Registered Nurse required.

Two years of nursing experience in primary care, community nursing, critical care or home health preferred

Essential Functions:

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.

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.

Utilize appropriate protocols and standing orders in delivering patient care.

Participate in regular team meetings, huddles, staff meetings and quality improvement projects to improve patient care.

Maintain annual competencies for role.

Document all communication with patient in electronic medical record.

Perform all other duties as assigned.

Competencies:

Ability to work independently and exercise clinical judgment in interactions with Physicians, payers, patients and their families. Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components. Aware of scope of practice boundaries, comfortable seeking direction and assistance from appropriate resources.

Communication – Ability to communicate effectively verbally and in writing. Excellent negotiation skills. Computer Skills – Proficient ability to use a computer and electronic medical record. Confidentiality – Maintain patient, team member and employer confidentiality. Comply with all HIPAA regulations. Customer Service Oriented – Friendly, cheerful and helpful to patients and others. Ability to meet patients and others needs while following office policies and procedures. Decision Making – Ability to make critical decisions while following organizational policies and procedures. Delegating – Ability to allocate authority and/or task responsibility to appropriate team members, peers or superiors. Flexibility – Ability to adapt easily to changing conditions and work responsibilities. Positivity – Display a positive attitude and is a positive agent for change. Project Management – Ability to organize and direct a project to completion. Teamwork – Work as part of a team and collaborate with co-workers. Working Under Pressure – Ability to complete assigned tasks under stressful situations.

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Physical Demands

Sit Walk Seeing (Visual) - Continuous     (68-100%)

Stand Reach Listening – Continuous     (68-100%)

Lift Carry Simple Grasping - Occasional     (1-33%)

Squat Distinguishing colors - Occasional     (1-33%)

Body Fluids - Frequent     (34-67%)

Kneel Firm Grasping - Occasional     (1-33%)

Climbing Stairs Forearm Rotation - Occasional     (1-33%)

Lifting 10-50 lb; Carrying Up to 10 lbs; Lifting > 50 lbs with assistance; Carrying 10 to 20 lbs - Occasional     (1-33%)

Use of Wheelchair Push on wheels 200-400 lbs - Occasional     (1-33%)
Use of Carts Use of Computer Carts Use of Dynamap (1 lb) - Occasional     (1-33%)