Annual Wellness Visit Clinical Support Specialist - Marshall Internal Medicine

Job description

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 • Identify missing or outdated preventive care information.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.