The Wellness Visit Nurse will serve in an expanded nursing role to perform Annual Wellness Visits per Medicare guidelines, promote preventative patient care, offer screening services, and coordinate disease management services with the provider, patient and their family. Primary responsibilities include identification of Medicare patients appropriate for annual wellness visits, execution of guided processes to complete the annual wellness visits, and ensures the medical record reflects the patient's chronic conditions to support the capture of Hierarchical Condition Categories (HCC). The Wellness Visit Nurse collaborates with the provider to order due or overdue preventive health tests and immunizations. Assists with integrating identified patient needs, intervention pathways, clinical guidelines, and diagnostic tests to develop individualized plans of care. The Wellness Visit Nurse must be knowledgeable of community resources and assists patients in connecting with those resources and serves as patient advocate. This position requires expertise in the nursing process and using critical thinking skills to plan and coordinate care.

NON-EXEMPT

Identifies Medicare patients appropriate for annual wellness visits through reporting mechanisms in EMR and payer reporting.

Executes guided processes to complete the annual wellness visits in an efficient manner.

Ensures the medical record reflects the patient's chronic conditions to support the capture of Hierarchical Condition Categories (HCC).

Reviews and adheres to all Medicare guidelines regarding the performance of Annual Wellness Visits.

Develops and shares knowledge of annual wellness visit eligibility and documentation requirements.

Follows annual wellness visit protocols and standing orders including completion of preventive services that may result from the annual wellness visit.

Develops knowledge of Medicare preventive services and clinical guideline recommendations for those services.

Builds positive, open communication between patients, caregivers, providers, and staff, and works as a team member to enhance the patient experience.

Addresses open quality care gaps with patients and works collaboratively with patient towards closure of those gaps

Documents within the electronic medical record to satisfy closed quality gaps.

Assesses the healthcare, educational and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions.

Investigates healthcare options and facilitates communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify options for treatment.

Uses motivational interviewing and shared decision-making modalities as appropriate to enhance patient engagement.

Educates patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.

Provides patient guidance on importance of closing gaps in care. Assists patients with scheduling appointments and placing orders using standing order protocols for the care they need to remain healthy and to ensure the best patient experience.

Reviews the current literature regarding effective teaching/learning strategies and disease management strategies and incorporates the appropriate techniques into practice.

Perform appropriate technique and processes for various nursing duties including immunization administration, point of care testing, various assessments, EKG, and others as required.

Utilizes knowledge of resources available within the healthcare system to assist and support both the healthcare provider and patient effectively.

Maintains an up-to-date knowledge of current quality programs and other programs that may develop over time.

Develops knowledge and remains current with evidence-based preventive services and clinical guideline recommendations for those services.

Assists with quality performance improvement plans and efforts; execute health campaigns, generate ideas to improve quality performance.

Provides coverage as needed for other department programs i.e., remote patient monitoring, case management.

Professional Requirements:

Adheres to dress code.

Completes annual educational requirements.

Maintains regulatory requirements.

Wears identification while on duty.

Maintains confidentiality at all times.

Attends department staff meetings as required within the department.

Reports to work on time and as scheduled; completes work in designated time.

Represents the organization in a positive and professional manner.

Actively participates in performance improvement and continuous quality improvement (CQI) activities.

Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards.

Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.

Complies with Benefis Health System Organization Policies and Procedures.

Complies with Health and Safety Standards and Guidelines.