Annual Wellness Visit (AWV) Chart Preparation
· Prepare comprehensive AWV charts to support provider efficiency and CMS compliance.
· Review and summarize with patients in face-to-face virtual visits via Zoom:
· Medical, surgical, and family histories
· Medication lists and adherence
· Preventive screenings and immunizations
· Cognitive, functional, and depression assessments
· Identify overdue screenings, risk factors, and care gaps prior to visits.
· Communicate concise patient summaries and key findings to providers before each AWV.
· Coordinate with patients to obtain missing or clarified information as needed.
· Ensure documentation meets Medicare, CMS, and organizational requirements.
Care Management & Clinical Oversight
· Provide telephonic and portal-based care management for medically complex patients with chronic, behavioral health, and socio-economic comorbidities.
· Conduct comprehensive nursing assessments addressing:
· Physical, functional, psychological, social, environmental, and learning needs
· Develop, implement, and monitor individualized care plans for: CCM, RPM, RTM, and APCM
· Complete care plan creation and annual updates for APCM, including goal-setting, interventions, and progress tracking.
· Utilize motivational interviewing to engage patients and caregivers in care planning and adherence.
· Monitor patient progress, reassess goals, identify barriers, and adjust care plans as needed.
· Communicate patient status and care plan updates to primary care providers and interdisciplinary care teams.
· Provide patient education, coaching, and support aligned with health literacy and cultural needs.
· Act as a patient advocate and assist with problem-solving and escalation when appropriate.
Care Navigation & Gap Closure
Actively work in care navigation to:
· Identify and close care gaps (preventive screenings, labs, medications, follow-ups).
· Coordinate and facilitate orders, referrals, and follow-up actions as needed.
· Monitor service delivery to ensure appropriateness, avoid duplication, and meet patient needs.
· Coordinate care across multiple services and providers to ensure continuity and quality.
Documentation, Quality & Compliance
· Maintain accurate, timely, and confidential patient records.
· Utilize electronic health record systems (CT360, RXNT, Zoom) and telehealth platforms effectively.
· Measure and support outcomes related to clinical quality, patient engagement, and satisfaction.
· Adhere to HIPAA, CMS, and organizational compliance standards.
· Participate in professional development and ongoing training.
· Demonstrate strong, independent decision-making, prioritization, and multitasking skills.
· Perform other duties as assigned.