Annual Wellness Visit Clinical Support Specialist - Marshall Internal Medicine

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• Identify missing or outdated preventive care information.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.