The Wellness Coordinator RN provides regularly scheduled preventative care annual visits in coordination with the provider in an effort to improve their overall health functioning. The Wellness Coordinator will schedule and perform Medicare Wellness visits for all CCA patients. They will collaborate with the health care team/provider to ensure the highest level of service is provided.
The ability to deliver direct patient care in primary care office completing the following:
1. Provides annual Medicare wellness visits for CCA patients.
2. Assist in pre-visit planning and identify patients who may benefit from an integrated visit with care
management/coordination services.
3. Is familiar with Medicare requirements and is able to perform within a given scope of practice.
4. Will work collaboratively with the providers to ensure the highest level of care.
5. In collaboration with patient and healthcare team, establishes individualized, objective action steps that are time
specific to assist the patient in improving their overall health.
6. Provides ongoing support and evaluation of progress toward stated health goals. Revises the healthcare plan as
needed in collaboration with patient and the provider.
7. Acts as an advocate for patient and helps them to obtain their maximum level of health. Provides education to
patients about their specific conditions and needs.
8. Possesses excellent communication and collaboration skills.
9. Involves patient’s family, community, and other natural supports when authorized by patient in an attempt to
promote a maximum level of independence.
10. Determines the need for and completes appropriate referral processes.
11. Maintains EHR documentation and data. Completes all documentation in a timely manner to ensure timely and
accurate billing from the provider.
12. Participates in regular team and organizational meetings. Participates on committees as applicable. Assists in the
orientation of new personnel. Promotes a collaborative atmosphere across the organization.
13. Provides educational opportunities and is a resource person for providers and staff.
16. Meets with Director of Patient Services/Regulatory Compliance regularly to provide patient and staff updates,
identify issues and develop strategies for resolution.
17. Develops and maintains relationships across organization. Displays compassion and skill in communication,
understanding, and motivating others to reach their highest potential.
18. Interacts harmoniously with others and contributes to an overall sense of wellbeing within the office setting.
focuses on the attainment of organizational goals and objectives and displays a commitment to teamwork.
19. Assists physicians and other team members in developing and implementing evidence-based practices and care
plans for target health populations.
20. Collect data on quality metrics and track as required for improvement efforts.
Collaborates with providers in the development, implementation, and evaluation of protocols and processes for the management of target populations that result in improved patient outcomes. |
Provides annual Medicare wellness visits for CCA patients. |
Schedules and maintains independent patient schedule of appointments |
Delivering direct patient care in primary care office performing physicals and other care in the scope of RN. |
Perform Nurse Triage for patients calling the office. |
Evaluates aspects of each patient’s condition, diagnoses, medications and support systems to formulate an individualized plan which will lead to successful outcomes in medication self-management, use of a patient-centered record, appropriate primary care and specialist follow-up. |
Serves as a guide to the patient and/or family/care, coaching the patient in addressing critical issues and self-management tasks families to achieve maximum levels of wellness and independence. |
Assist in pre-visit planning and identify patients who may benefit from an integrated visit with care management/coordination services. |
Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in all age groups |
Provides information and guidance to the patient and/or family for an effective care transition, improved self-management skills and enhances patient-practitioner communication |
Confers, as appropriate, with providers and other members of the healthcare team regarding the medical plan of care, and post-acute care needs. |
Fosters communication among clinical treatment team, patient, family and post-acute providers. |
Maintains a working knowledge of, and adheres to applicable federal/state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA. |
Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing. |
Meets established standards for Registered Professional Nurses continuing education annually. |
All of duties as assigned. |
