North East Medical Services
MSO ANNUAL WELLNESS VISIT (AWV) REGISTERED NURSE
North East Medical Services, Burlingame, California, United States, 94012
Job Details
Job Location : Burlingame, CA
Salary Range : $131783.60 - $151736.00 Salary Description SUMMARY OF POSITION: The Annual Wellness Visit (AWV) Registered Nurse (RN) plays a critical role in improving patient outcomes through comprehensive wellness assessments, early identification of high-risk conditions, and coordinated care planning. The AWV RN is responsible for completing Medicare-compliant AWV assessments, evaluating patients for eligibility into case management programs, creating individualized care plans (ICP), and leading interdisciplinary team (IDT) discussions involving the patient, PCP, and broader care team. The position requires strong assessment, clinical judgment, and care planning skills. The AWV RN must have excellent communication and facilitation skills to promote effective ICP and IDT. Ability to collaborate effectively within interdisciplinary teams, proficient in Epic and EZCARE uses and documentation, familiarity with CMS guidelines and care management criteria are all essential requirements for the job. The position involves both in-office and remote/telehealth assessments; local travel may be required for in-home or on-site patient visits. This will be an important component in the NEMS case management program.
ESSENTIAL JOB FUNCTIONS:
AWV Execution: Responsible for conducting thorough, Medicare-compliant AWV assessments including health risk appraisals, screening for cognitive, functional, and mental health issues, medication reviews, preventive service planning, and documentation. Risk identification and Enrollment: Analyze assessment data to identify patients who meet criteria for case or disease management programs based on clinical risk, social determinants of health, and utilization patterns. Individualized Care Plan Development: Develop patient-centered care plans that address identified health risks, goals, barriers, and support needs. Coordinate referrals, preventive services, and follow-up interventions as appropriate. Interdisciplinary Team Conferencing: Facilitate structured care conferences with patients, PCPs, and care team members (e.g., social workers, pharmacists, behavioral health providers) to ensure collaborative, goal-oriented care planning. Documentation and Reporting: Accurately document all assessments, care plans, and conference outcomes in Epic and/or EZCAP. Ensure timely completion of reports and program-specific documentation. Patient Engagement and Education: Empower patients through health education, goal setting, and motivational interviewing to promote self-management and preventive care adherence. QI Program Participation: Contribute to ongoing quality improvement initiatives related to care coordination, case management, preventive health, and patient engagement outcomes. Provide coverage for the Case Management team to conduct post-discharge home visits. Performs other job duties as required by manager/supervisor.
QUALIFICATIONS:
Bachelor’s degree required. Valid California Registered Nurse license. Valid Driver License and ability to maintain good driving record. Current Basic Life Support certification required Demonstrate willingness to make decisions within RN's clinical scope of practice, exhibit sound, accurate, and ethical judgment. 2-3 experience in case management preferred Knowledge of Medicare Annual Wellness Visit requirements preferred. Ability to provide detailed, concise notes/documentation of work within workflow turn-around timelines. Ability to engage and work collaboratively with others, including patients, patient's families, clinical team members, organization leadership, and community resources. Good communication and interpersonal skills; ability to work with people from diverse backgrounds and experiences. Time management and prioritization skills are vital. LANGUAGE: Must be able to fluently speak, read, and write English. Fluency in Chinese (Cantonese and Mandarin) required. Fluency in other languages is an asset. STATUS: This is an FLSA Exempt position. This is not an OSHA high-risk position. This is a Full Time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
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Job Location : Burlingame, CA
Salary Range : $131783.60 - $151736.00 Salary Description SUMMARY OF POSITION: The Annual Wellness Visit (AWV) Registered Nurse (RN) plays a critical role in improving patient outcomes through comprehensive wellness assessments, early identification of high-risk conditions, and coordinated care planning. The AWV RN is responsible for completing Medicare-compliant AWV assessments, evaluating patients for eligibility into case management programs, creating individualized care plans (ICP), and leading interdisciplinary team (IDT) discussions involving the patient, PCP, and broader care team. The position requires strong assessment, clinical judgment, and care planning skills. The AWV RN must have excellent communication and facilitation skills to promote effective ICP and IDT. Ability to collaborate effectively within interdisciplinary teams, proficient in Epic and EZCARE uses and documentation, familiarity with CMS guidelines and care management criteria are all essential requirements for the job. The position involves both in-office and remote/telehealth assessments; local travel may be required for in-home or on-site patient visits. This will be an important component in the NEMS case management program.
ESSENTIAL JOB FUNCTIONS:
AWV Execution: Responsible for conducting thorough, Medicare-compliant AWV assessments including health risk appraisals, screening for cognitive, functional, and mental health issues, medication reviews, preventive service planning, and documentation. Risk identification and Enrollment: Analyze assessment data to identify patients who meet criteria for case or disease management programs based on clinical risk, social determinants of health, and utilization patterns. Individualized Care Plan Development: Develop patient-centered care plans that address identified health risks, goals, barriers, and support needs. Coordinate referrals, preventive services, and follow-up interventions as appropriate. Interdisciplinary Team Conferencing: Facilitate structured care conferences with patients, PCPs, and care team members (e.g., social workers, pharmacists, behavioral health providers) to ensure collaborative, goal-oriented care planning. Documentation and Reporting: Accurately document all assessments, care plans, and conference outcomes in Epic and/or EZCAP. Ensure timely completion of reports and program-specific documentation. Patient Engagement and Education: Empower patients through health education, goal setting, and motivational interviewing to promote self-management and preventive care adherence. QI Program Participation: Contribute to ongoing quality improvement initiatives related to care coordination, case management, preventive health, and patient engagement outcomes. Provide coverage for the Case Management team to conduct post-discharge home visits. Performs other job duties as required by manager/supervisor.
QUALIFICATIONS:
Bachelor’s degree required. Valid California Registered Nurse license. Valid Driver License and ability to maintain good driving record. Current Basic Life Support certification required Demonstrate willingness to make decisions within RN's clinical scope of practice, exhibit sound, accurate, and ethical judgment. 2-3 experience in case management preferred Knowledge of Medicare Annual Wellness Visit requirements preferred. Ability to provide detailed, concise notes/documentation of work within workflow turn-around timelines. Ability to engage and work collaboratively with others, including patients, patient's families, clinical team members, organization leadership, and community resources. Good communication and interpersonal skills; ability to work with people from diverse backgrounds and experiences. Time management and prioritization skills are vital. LANGUAGE: Must be able to fluently speak, read, and write English. Fluency in Chinese (Cantonese and Mandarin) required. Fluency in other languages is an asset. STATUS: This is an FLSA Exempt position. This is not an OSHA high-risk position. This is a Full Time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
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