Overview Join our dynamic healthcare team as a Wellness Registered Nurse, where your expertise will empower individuals to achieve optimal health and well-being. In this vital role, you will deliver comprehensive nursing care, coordinate wellness programs, and provide personalized health education. Your energetic approach will inspire positive health outcomes and foster a supportive environment for diverse patient populations. We are committed to creating a vibrant workplace that values innovation, compassion, and professional growth. Responsibilities Participate in care coordination, quality improvement, educational, research, community outreach, and population health activities as requested. Identify eligible patients and enroll them in Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and other applicable care-management programs in accordance with organizational policies and payer requirements. Obtain and document patient consent for participation in CCM, RPM, and related care-management services, as required. Conduct comprehensive assessments of patients' medical, behavioral, functional, psychosocial, and health-related social needs. Serve as an extension of the patient's primary care provider by facilitating timely communication and correspondence with home health agencies, hospitals, specialists, pharmacies, durable medical equipment suppliers, and other external organizations. Develop, implement, maintain, and periodically update individualized, patient-centered comprehensive care plans in collaboration with the patient, provider, caregiver, and interdisciplinary care team. Coordinate and perform \Medicare Annual Wellness Visits (AWVs), including health risk assessments, medication reconciliation, functional and cognitive screenings, depression and fall-risk screenings, review of medical and social history, identification of preventive care needs, and development of a personalized prevention plan. Coordinate and perform permitted Welcome to Medicare visits. Review patient records before wellness visits to identify care gaps, overdue screenings, immunizations, preventive services, and chronic disease monitoring needs. Support Patient-Centered Medical Home (PCMH) recognition, compliance, documentation, reporting, and ongoing quality-improvement activities. Provide clinical coverage at assigned clinic locations during peer absences or periods of increased operational need. Perform monthly CCM outreach and maintain meaningful communication with enrolled patients or caregivers regarding health status, treatment goals, medication adherence, appointments, referrals, and barriers to care. Monitor and document the time spent providing billable care-management services in accordance with CMS, payer, coding, and organizational requirements. Review RPM data according to established monitoring protocols. Contact patients regarding missing, inconsistent, or concerning RPM readings and provide education or troubleshooting related to the proper use of monitoring equipment. Recognize abnormal findings, changes in condition, or warning signs and promptly escalate clinical concerns to the appropriate provider or emergency service according to established protocols. Maintain accurate, timely, and complete documentation of RPM reviews, patient communications, clinical interventions, provider notifications, and follow-up actions. Educate patients and caregivers regarding chronic disease management, medications, nutrition, physical activity, tobacco cessation, preventive care, symptom monitoring, and appropriate use of healthcare services. Establish individualized patient goals and provide education that promotes self-management, informed decision-making, and adherence to the established plan of care. Use motivational interviewing, teach-back, and other evidence-based education techniques to evaluate patient understanding and encourage sustainable health behavior changes. Promote completion of Annual Wellness Visits, preventive screenings, immunizations, laboratory testing, referrals, and other recommended services for patients participating in care-management programs. Coordinate follow-up after emergency department visits, hospital admissions, hospital discharges, specialist visits, and significant changes in the patient's condition. Provide enhanced care coordination for high-risk patients with chronic conditions and serve as a liaison among the patient, caregiver, hospital, primary care provider, specialists, home health agency, behavioral health team, and community service organizations. Identify barriers to care, including transportation, medication affordability, food insecurity, housing instability, health literacy, and caregiver limitations, and connect patients with appropriate internal or community resources. Participate in interdisciplinary care-team meetings, case reviews, daily huddles, and quality-improvement activities as assigned. Collaborate with clinical, Quality Improvement, Billing, Coding, and Information Technology personnel to support accurate documentation, compliant billing, reliable reporting, and effective program performance. Maintain patient confidentiality and comply with HIPAA, OSHA, infection-control requirements, CMS guidance, payer requirements, organizational policies, and applicable professional nursing standards. Maintain current knowledge of CCM, RPM, Medicare preventive services, chronic disease management, and patient-education practices through continuing education and required training. Perform other duties as assigned. Skills Proven experience working with diverse populations including seniors, individuals with developmental disabilities, or those in hospice & palliative medicine. Strong knowledge of medical terminology, anatomy, physiology, and diagnostic evaluation techniques. Proficiency in EMR/EHR systems such as Athenahealth or eClinicalWorks; familiarity with ICD-10 coding is preferred. Ability to perform triage effectively in urgent care or outpatient environments; adept at handling acute pain management cases. Knowledge of infection control protocols, sterile processing techniques, and laboratory specimen collection/processing. Excellent communication skills for patient education and case management; experience working with children or individuals with disabilities is advantageous. Join us if you're passionate about making a difference through energetic nursing practice that combines technical expertise with compassionate patient care!

Pay:

$24.00 - $32.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Life insurance Vision insurance

Work Location:

In person