RN - Annual Wellness Visits
- 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.
- 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
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