MSO Annual Wellness Visit (Awv) Physician Assistant

The Annual Wellness Visit (AWV) Physician Assistant (PA) plays a critical role in improving patient outcomes through conducting comprehensive preventive care for Medicare patients. This includes early identification of high-risk conditions, creating personalized prevention plans, coordinating preventive services, and documenting visits to meet payer and regulatory requirements, including accurate capturing of Hierarchical Condition Categories (HCCs). The AWV PA is responsible for completing AWVs, including completing a detailed evaluation of the medical and social assessment of the patients, identifying health risks, reviewing medical history, screening for cognitive/functional impairment, and collaborating with primary care teams.

The position requires strong assessment, clinical judgment, and team collaboration. The AWV PA must have excellent communication and facilitation skills. Ability to collaborate effectively within interdisciplinary teams, proficiency in Epic, detailed and accurate chart documentation, and familiarity with CMS guidelines 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 position will be an important component of the NEMS AWV Program.

ESSENTIAL JOB FUNCTIONS:

• Conduct Medicare Annual Wellness Visits (initial and subsequent) including a health risk assessment, medical/family/social history update, medication reconciliation, and review of functional status and cognitive risk.
• Review preventive screening (e.g., depression screening, fall risk, cognitive screening) results and discuss appropriate follow-up or referrals.
• Develop and document a personalized prevention plan (PPS) that lists recommended preventive services, screening schedules, and health promotion counseling.
• Reconcile medications and review immunization status; order vaccines, labs, imaging, or specialty referrals as indicated.
• Provide patient education on prevention, chronic disease self-management, lifestyle changes, advance care planning, and community resources.
• Ensure AWV documentation meets Medicare and organizational documentation/billing requirements; enter visit data accurately in the EHR and use appropriate visit codes per clinic policy.
• Complete appropriate documentation of all evaluations, care, and services rendered in the medical record within 72 hours of encounters
• Coordinate care with primary care providers, specialists, case managers, social workers, and community services to close care gaps.
• Track AWV-related quality metrics and participate in quality improvement efforts to increase AWV completion and preventive service adherence.
• Maintain up-to-date knowledge of preventive care guidelines and Medicare AWV rules relevant to practice.
• Support telehealth AWV workflows where applicable.
• Performs other job duties as required by manager/supervisor.