Quality & Annual Wellness Visit Nurse ( RN )

At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence-based practice to improve outcomes – to every patient, every time.

The Quality & Annual Wellness Visit Nurse will serve in an expanded nursing role to perform Annual Wellness Visits per Medicare guidelines, promote preventative patient care, offer screening services, and coordinate disease management services with the provider, patient and their family. This Nurse will review health maintenance and educate on same, and will collaborate with providers to order due or overdue preventive health tests and immunizations.

Responsibilities:

• Perform Annual Wellness Visit in accordance with Payer and CH guidelines.
• Assess the healthcare, educational, and psychosocial needs of the patient/family and involves them in establishing a treatment plan based on realistic goals and interventions.
• Investigate healthcare options and facilitate communication among the patient, primary care provider and other members of the healthcare team to eliminate barriers and identify interventions for treatment.
• Use motivational interviewing and shared decision-making modalities as appropriate to enhance patient engagement.
• Educate patient, family and other health care members on the role and purpose of Care Coordination, its processes, disease/case management programs and outcomes and makes referral to appropriate Care Coordination services as needed.
• Collaborate with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. Coordinate laboratory and diagnostic tests for disease management and value-based payment programs.
• Collect and enter data and patient information into the medical record according to department and CH standards.
• Attend and participate in professional and nursing continuing education programs and professional development opportunities.
• Review the current literature regarding effective teaching/learning strategies and disease management strategies and incorporate the appropriate techniques into practice.
• Incorporate excellent written, verbal, and listening communication skills, team-building skills, and critical thinking skills in disease management practice.

Qualifications:

• Education: Bachelor of Science in Nursing (BSN) degree required; Master of Science degree preferred
• Licensure: New York Registered Nurse (RN) License & Registration required

• Prior population health experience preferred; AWV familiarity a plus.
• Minimum of 3 years ambulatory experience required
• Strong background in ambulatory care prevention, health promotion, condition management, case management and discharge planning.
• Mastery of theories, principles and methodologies underlying population health management and clinical preventative services.
• Knowledge of contemporary practice transformation models, e.g., PCMH, APC
• Proficient in Microsoft Office (Excel, Power Point, and Microsoft Word), Outlook (email), and internet familiarity is required.
• Knowledge of EMR (EPIC preferred)

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job and it does not include the value of benefits.