Essential Duties and Responsibilities
Annual Wellness Visit Pre-Visit Outreach:- Review upcoming AWV schedules and identify patients requiring pre-visit questionnaire completion.
- Contact patients by telephone sufficiently in advance of their scheduled AWV.Explain the purpose of the pre-visit questionnaire and obtain patient cooperation and accurate responses.
- Complete standardized AWV pre-visit questionnaires and required health risk assessment components within the scope of licensure and organizational protocols.
- Obtain and document information related to:
- Activities of daily living and instrumental activities of daily living.
- Fall risk and safety concerns.
- Cognitive and functional status.
- Depression and other approved screening assessments.
- Social determinants of health, as applicable.
- Medication use and medication-related concerns.
- Preventive health services and screening history.
- Immunization status.
- Advance care planning, when applicable.
- Health behaviors and lifestyle factors.
- Other information required to support completion of the AWV.Clinical Record Review and Preparation
- Review the patient's medical record before completing the telephone questionnaire when appropriate.
- Identify missing or outdated preventive care information.
- Reconcile or update information within the RN/LPN's authorized scope.
- Identify potential gaps in preventive services, including screenings, immunizations, laboratory testing, or other recommended services.
- Ensure relevant information is accurately entered into the electronic medical record.
- Prepare concise clinical information for the provider to review during the AWV.Follow established workflows for routing clinical questions, abnormal screening responses, or other concerns to the appropriate provider or clinical team member.
Patient Communication and Education:
Provide patients with clear instructions regarding the purpose and process of the AWV.Educate patients regarding preparation for the visit, including bringing medication information, advance directive documentation, or other requested information.
Reinforce preventive health recommendations within the individual's scope of practice and established protocols.
Use effective telephone communication skills to establish rapport with patients and encourage completion of the pre-visit process.
Recognize barriers to care and communicate identified needs to the appropriate clinical or administrative team.
Clinical Escalation:
Recognize and appropriately escalate clinical concerns identified during the pre-visit telephone encounter.
Immediately communicate urgent or potentially emergent concerns according to departmental protocols.
Route abnormal screening results or patient-reported symptoms to the appropriate RN, APP, physician, or other designated clinician.
Do not independently diagnose, treat, or provide clinical recommendations outside the individual's scope of practice, established protocols, or delegated authority.
Document all clinical concerns and actions taken in accordance with organizational standards.
Workflow and Quality Improvement:
Maintain a consistent and timely pre-AWV outreach workflow.
Coordinate with scheduling staff to identify cancellations, rescheduled appointments, and patients requiring additional outreach.
Re-attempt contact with patients who cannot initially be reached according to established outreach protocols.
Document unsuccessful outreach attempts accurately.
Identify recurring barriers or inefficiencies in the AWV process and communicate recommendations for improvement.
Participate in departmental quality improvement initiatives related to preventive care, AWV completion, patient access, documentation accuracy, and clinical workflow.
Assist in monitoring AWV-related performance metrics as assigned.
Documentation Responsibilities:
Document telephone encounters accurately, timely, and completely.
Enter questionnaire responses into the appropriate sections of the electronic medical record.
Maintain appropriate documentation of outreach attempts.
Clearly identify information requiring provider follow-up.
Maintain patient confidentiality and comply with HIPAA and organizational privacy and security requirements.
Ensure documentation supports appropriate clinical communication and continuity of care.
Performance Expectations:
The RN/LPN - Annual Wellness Visit Clinical Support Specialist is expected to:
Complete assigned pre-AWV outreach within established timeframes.
Maintain a high level of accuracy when collecting and entering patient information.
Maximize successful patient contact and questionnaire completion.
Minimize incomplete or duplicate AWV documentation.
Identify and appropriately escalate clinical concerns.
Maintain professional and compassionate communication with patients.
Support efficient provider workflows by ensuring information is available before the AWV.Consistently follow established AWV protocols and scope-of-practice requirements.
Internal applicants must call HR at ext. 11653 to determine eligibility before applying.
