Annual Wellness Visit RN - Remote and Part-Time!

About the role

The Annual Wellness Visit (AWV) Registered Nurse is responsible for coordinating and conducting Medicare Annual Wellness Visits in accordance with CMS guidelines. The RN works collaboratively with primary care providers and the interdisciplinary care team to identify preventive care needs, close quality gaps, promote chronic disease management, and improve patient outcomes while ensuring accurate documentation within the electronic health record (EHR).

Responsibilities

• Conduct Medicare Initial Preventive Physical Exams (IPPE), Initial Annual Wellness Visits, and Subsequent Annual Wellness Visits according to CMS requirements.
• Obtain and document comprehensive patient histories, including: Medical and surgical history, Family history, Social history, Current medications and allergies.
• Perform and document: Health Risk Assessment (HRA), Functional status assessment, Fall risk screening, Depression screening (PHQ-2/PHQ-9 as appropriate), Cognitive assessment, Safety assessment, Advance care planning discussions.
• Record vital signs and other required clinical measurements.
• Develop and update each patient’s Personalized Prevention Plan.
• Identify and close preventive care gaps. Review immunization status and recommend appropriate vaccines. Ensure recommended screenings are ordered or scheduled, including: Mammograms, Colon cancer screening, Bone density testing, Lung cancer screening, Abdominal aortic aneurysm screening, Hepatitis C screening. Coordinate referrals for preventive services when appropriate.
• Carefully collaborate with physicians, nurse practitioners, physician assistants, care managers, referral coordinators, and ancillary departments. Identify patients who may benefit from Chronic Care Management (CCM), or other care management programs. Coordinate follow-up appointments for medical conditions identified during the wellness visit. Communicate abnormal findings to the patient’s provider.
• Complete all documentation accurately and timely within the EHR. Ensure compliance with CMS, Medicare, payer, and organizational documentation standards. Assist with quality reporting initiatives, including MIPS, ACO, HEDIS, and other value-based care programs. Support accurate coding by documenting required components of the Annual Wellness Visit.
• Educate patients regarding: Preventive health recommendations, Lifestyle modifications, Nutrition and exercise, Tobacco cessation, Fall prevention, Medication adherence, Advance directives.

Requirements

• Graduate of an accredited Registered Nursing program.
• Current RN license in the applicable state.
• BLS certification required.
• Experience with value-based care initiatives.