MSO ANNUAL WELLNESS VISIT (AWV) NURSE PRACTITIONER

About the role

The Annual Wellness Visit (AWV) Nurse Practitioner (NP) plays a critical role in improving patient outcomes through conducting comprehensive preventive care for Medicare patients. This includes early identification of high-risk conditions, creating personalized prevention plans, coordinating preventive services, and documenting visits to meet payer and regulatory requirements, including accurate capturing of Hierarchical Condition Categories (HCCs).

Responsibilities

• Conduct Medicare Annual Wellness Visits (initial and subsequent) including a health risk assessment, medical/family/social history update, medication reconciliation, and review of functional status and cognitive risk.
• Review preventive screening (e.g., depression screening, fall risk, cognitive screening) results and discuss appropriate follow-up or referrals.
• Develop and document a personalized prevention plan (PPS) that lists recommended preventive services, screening schedules, and health promotion counseling.
• Reconcile medications and review immunization status; order vaccines, labs, imaging, or specialty referrals as indicated.
• Provide patient education on prevention, chronic disease self-management, lifestyle changes, advance care planning, and community resources.
• Ensure AWV documentation meets Medicare and organizational documentation/billing requirements; enter visit data accurately in the EHR and use appropriate visit codes per clinic policy.
• Complete appropriate documentation of all evaluations, care, and services rendered in the medical record within 72 hours of encounters.
• Carefully coordinate care with primary care providers, specialists, case managers, social workers, and community services to close care gaps.
• Track AWV-related quality metrics and participate in quality improvement efforts to increase AWV completion and preventive service adherence.
• Maintain up-to-date knowledge of preventive care guidelines and Medicare AWV rules relevant to practice.
• Support telehealth AWV workflows where applicable.

Qualifications

• Active Nurse Practitioner (NP) license in California.
• National certification as an NP (e.g., AANP, ANCC) appropriate to population focus (Family NP, Adult-Gerontology NP, or geriatric NP preferred).
• Current Basic Life Support certification required.
• Demonstrate willingness to make decisions within NP's clinical scope of practice, exhibit sound, accurate, and ethical judgment.
• Minimum of 1-2 years clinical experience (Previous experience in Medicare AWV, geriatric care, primary care, or chronic disease management is highly preferred).
• Knowledge of Medicare Annual Wellness Visit requirements preferred.
• Proficiency with Epic electronic health records and basic clinical documentation and billing workflows.
• Ability to engage and work collaboratively with others, including patients, patient's families, clinical team members, organization leadership, and community resources.
• Strong communication, teaching, and care coordination skills; ability to work with people from diverse backgrounds and experiences.
• Time management and prioritization skills are vital.
• Familiarity with preventive care quality metrics, care-gap closure initiatives, and population health programs is preferred.

Qualifications - Language

• Must be able to fluently speak, read, and write English.
• Fluency in Chinese (Cantonese and Mandarin) preferred.
• Fluency in other languages is an asset.