Annual Wellness Visit Nurse - Family Medicine-PBC

Job Responsibilities:

Conducts Annual Wellness Visits: Perform detailed health assessments, including reviewing medical histories, evaluating current health conditions, and identifying potential health risks. Assist in identifying patients who may benefit from an integrated visit with care management/coordination services.

Patient Education: Provide patients with information on preventive health practices, lifestyle modifications, and chronic disease management. Provides ongoing support and evaluation of progress toward stated health goals. Revises the healthcare plan as needed in collaboration with patient and healthcare team.

Data Collection and Documentation: Accurately document patient information, including vital signs, health histories, and screening results, in electronic medical records (EMR). Completes all documentation in a timely manner.

Risk Assessment: Identify and assess potential health risks based on patient data and provide recommendations for preventive care and follow-up actions.

Collaboration: Work closely with physicians, nurse practitioners, and other healthcare team members to develop and implement individualized care plans. Participates in regular team and organizational meetings. Assists in the orientation of new personnel for quality improvement and population health. Promotes a collaborative atmosphere across the organization. Collaborates with the RN Quality Manager in improving quality metrics, care coordination, and assisting in enrollment and support of care management programs.

Care Coordination: Assist in coordinating referrals, follow-up appointments, and additional screenings or tests as necessary. Acts as an advocate for patients and helps them to obtain their maximum level of health. Provides education to patients about their specific conditions and needs.

Patient Engagement: Foster a supportive environment for patients, encouraging them to take an active role in their health and wellness.

Compliance: Ensure that all activities are conducted in accordance with applicable laws, regulations, and organizational policy.

Performs other duties as assigned or requested.