Wellness Nurse

• Directly meets with patients to complete “Welcome to Medicare Visit” and the Medicare AWV and fulfill the Medicare requirements to bill.
• Obtain the following measurements:
  • Height, weight, body mass index (or waist circumference, if appropriate)
  • Blood pressure
  • Other routine measurements as deemed appropriate based on medical and family history.
• Develops an efficient process for AWV, to include: AWV identification, communication, scheduling and follow-up through collaboration with Medical Providers and office staff.
• Administer/review Health Risk Assessment (HRA) including: Self-assessment of health status: Psychosocial risks; Behavioral risks; Activities of Daily Living (ADLs), including, but not limited to dressing, bathing, and walking; and instrumental ADLs.
• Works with Payer Relations to identify eligible Medicare patients for AWVs (Welcome, Initial and/or Subsequent) and completes the AWV according to Medicare best practice guidelines.
• Ensures that AWVs are coded accurately for compliance and financial opportunity purposes.
• Provides age-based, cultural and language appropriate patient education.
• Encourages and facilitates patient self-management of disease, behavior modification interventions, and home monitoring within the scope of an AWV.
• Oversees implementation, sustainability and process improvement for the AWVs including EHR documentation, auditing for quality metrics and financial reimbursement, and providing ongoing education for providers, office staff, and coders on Medicare updates.
• Utilizes and documents appropriate patent referrals including preventive screening, though collaboration with Care Coordinators, Care Manager, and other Care Team members.
• Promotes clear communication amongst the care team.
• Facilitates the reconciliation process of patient medication.
• Works with assigned practices as appropriate and agreed upon to engage patients which may include but not limited to:
  • Directly engaging patients to ensure screening and other required preventative tests and appointments are completed.
  • Engaging patients through mailings, phone calls or other methods and working with practice to build a process to engage patients going forward.
  • Working with laboratories and other vendors as required to collect and enter patient results in the EHR.
• Required to attend meetings as necessary.
• Demonstrates knowledge of performance improvement by participating in collecting, compiling, and analyzing patient data.
• Communicates specific pieces of the plan of care to appropriate care team members.

• Perform AWVs.
• Assess chronic conditions and preventative care.
• Develop resources for training other wellness nurses.
• Explain processes and forms.
• Obtain health history through interviews.
• Educate patients regarding health promotion/illness prevention.
• Comply with all required elements of the Medical Annual Wellness.
• Understands and adheres to regulations for FQHCs and Primary Care Centers. Maintains a comprehensive working knowledge of community resources, payer requirements, and network services for target populations.
• Understands population health and works collaboratively with the health care team to promote health and wellness.
• Develops a strong knowledge of our electronic medical record and the reporting capabilities.
• Works intimately with IT staff and Patient Care Teams to improve quality outcomes.

• Communication: Conveys information accurately and efficiently.  Written communication is direct, concise, and easy to understand.
• Decision-making: Gathers necessary information to make good and timely decisions. Uses sound judgment and instincts. Seeks direction from Leadership appropriately.
• Supporting/Assisting: Seeks opportunities to help others be successful in meeting goals. Demonstrates behaviors reflective of our mission when helping others.
• Planning/Priority setting: Organizes tasks and objectives in order of importance, timing, and predicted results. Works within measurable goals and outcomes.
• Problem solving: Works systematically to solve problems. Develops reasonable and timely resolutions.
• Initiative: Takes prompt action to accomplish objectives. Seeks to resolve problems without being asked. Seeks direction from Leadership appropriately.
• Grace Health recognizes that managing patient care is a team effort that involves clinical and non-clinical staff. All employees must embrace a team-based approach to patient care and understand that each role is important to our success.
• Team members must demonstrate excellent team communication and coordination to provide quality patient care.
• Care coordination includes communicating with community organizations, health plans, facilities, and specialists.
• Care team members understand and embrace the concept of population management and proactively address the needs of patients and families served by this practice.
• Team members must demonstrate skill and knowledge related to effective communication with vulnerable patient populations.
• Team members must participate in Continuous Quality Improvement activities within the organization to ensure patients receive high quality care.
• All team members will be involved in the process of improving quality incomes.
• Team members will participate in the review and evaluation processes of practice performance and help to identify opportunities for improvement.
• Team members will participate in Grace Health's advocacy program.

• Follows policies and procedures of the clinic and evidence-based guidelines for patient care.
• Maintains appropriate time and adheres to staff requirements outlined in the Employee Handbook.
• Maintains timely documentation of all work assignments.
• Always maintain patient confidentiality.
• Routinely keeps supervisor informed.
• Flexible in being able to multi-task.
• Works effectively and at an efficient pace.
• Works cooperatively with providers, leadership, and other staff.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Demonstrates continual learning skills effects changes in approach to care based on established, evidence-based practice.
• Uses motivational interviewing with patients/families/staff members.
• Provides mentoring/coaching to other staff as needed.
• Other duties as assigned by supervisor.

• Communication
• Computer/Technology
• Conflict resolution
• Customer service
• Team building
• Time management
• Critical thinking
• Leadership
• Motivational Interviewing
• Health Literacy

• Current Kentucky Registered Nursing license required.
• Certified by the American Heart Association in Cardiopulmonary Resuscitation (CPR).
• More than one year’s experience required.
• Experience in Ambulatory Care Clinics preferred.

Grace Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.