RN - Annual Wellness Visits

Lynn Community Health Center
Lynn, MA
An AWV ( Annual Wellness Visit) RN conducts preventive health visits for Medicare patients to perform health risk assessments, create personalized care plans, document medical histories, and connect patients with community resources. Key responsibilities include identifying eligible patients, assessing their health needs, providing patient education on prevention, collaborating with primary care teams, and ensuring accurate Medicare compliance and documentation. The role requires strong communication skills, knowledge of CMS guidelines , and potentially involves in-home or remote patient care.

Per diem/Part time Hours

Key Responsibilities

  • Patient Identification & Scheduling: Identify Medicare patients eligible for an Annual Wellness Visit and schedule appointments.
  • Health Risk Assessments: Conduct comprehensive health risk assessments, which include reviewing medical and family histories, current medications, functional abilities, and mental health conditions.
  • Care Planning: Develop individualized care plans (ICPs) with the primary care provider, outlining preventive care services and interventions for the next 5-10 years.
  • Patient Education: Provide personalized health advice and educate patients on preventive health measures, lifestyle modifications, and available wellness resources.
  • Documentation & Compliance: Accurately document findings in the electronic medical record (EMR) and ensure all documentation and coding comply with Medicare and CMS guidelines .
  • Care Coordination: Collaborate with the patient's primary care provider and the broader healthcare team to address identified healthcare needs and coordinate follow-up care.
  • Resource Connection: Assist patients in connecting with relevant community resources and social services.
  • Patient Advocacy: Serve as a patient advocate to help improve service delivery and empower patients in their own care.

Required Skills & Qualifications

  • Nursing Licensure: Current licensure as a Registered Nurse (RN).
  • Clinical Skills: Strong nursing assessment, clinical judgment, and care planning skills are essential.
  • Communication: Excellent communication and facilitation skills for interacting with patients and the interdisciplinary team.
  • Knowledge: Proficiency in Medicare guidelines, preventative services, and electronic health record systems.
  • Collaboration: Ability to work effectively within a diverse interdisciplinary healthcare team.
  • Flexibility: Ability to perform in-office, remote/telehealth, or in-home patient visits, with potential local trave

Please apply now and grow with LCHC.

Thank you !
Posted 2025-11-14

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