We are seeking a compassionate, organized, and patient-focused Registered Nurse (RN) Wellness Coordinator to lead and coordinate our Annual Wellness Visit (AWV) program within a primary care setting.
The RN Wellness Coordinator will be responsible for coordinating, conducting, and supporting Medicare Annual Wellness Visits while helping patients stay up to date with preventive care and chronic disease management. This role will work closely with primary care providers, clinical staff, and administrative teams to ensure patients receive comprehensive, timely, and well-coordinated preventive care.
The ideal candidate is an RN who enjoys patient education, preventive health, care coordination, and working independently while collaborating effectively with a multidisciplinary primary care team.
Key Responsibilities
Annual Wellness Visits
- Coordinate and conduct Medicare Annual Wellness Visits in accordance with applicable CMS and organizational requirements.
- Perform comprehensive health risk assessments and review patient medical, medication, and social histories.
- Identify preventive care needs, health risks, and gaps in care.
- Develop and document individualized preventive care plans.
- Review and update preventive screening recommendations, immunizations, and health maintenance needs.
- Provide patient education regarding preventive health, wellness, lifestyle modification, and risk reduction.
- Coordinate appropriate follow-up with primary care providers and other members of the care team.
- Ensure AWV documentation is complete, accurate, and submitted in a timely manner.
Care Coordination & Preventive Health
- Monitor patient populations to identify individuals due for annual wellness visits and preventive services.
- Assist with outreach to patients who are due or overdue for AWVs and recommended screenings.
- Coordinate referrals, testing, follow-up appointments, and other preventive services as appropriate.
- Collaborate with providers to address identified health risks and care gaps.
- Support chronic disease management and population health initiatives.
- Help improve patient adherence to recommended screenings, vaccinations, and preventive services.
Clinical Responsibilities
- Perform nursing assessments and collect relevant clinical information.
- Reconcile medications and identify potential medication-related concerns for provider review.
- Obtain and document vital signs and other appropriate clinical data.
- Recognize changes in patient condition and communicate concerns to the appropriate provider.
- Follow established clinical protocols, infection-control standards, and organizational policies.
- Maintain accurate and timely electronic medical record documentation.
Patient Experience & Education
- Establish trusting relationships with patients and families.
- Provide clear, compassionate education tailored to individual patient needs.
- Encourage patients to actively participate in their health and wellness goals.
- Promote preventive care and healthy lifestyle practices.
- Serve as a resource for patients navigating primary care services.
Team Collaboration & Program Development
- Work closely with physicians, advanced practice providers, medical assistants, care managers, and administrative staff.
- Participate in quality-improvement initiatives related to preventive care and AWV performance.
- Track program activity and identify opportunities to improve AWV completion and patient outcomes.
- Assist with development and refinement of workflows for AWV scheduling, outreach, documentation, and follow-up.
- Maintain familiarity with applicable Medicare, CMS, and payer requirements related to Annual Wellness Visits.
Qualifications
Required:
- Current, unrestricted Registered Nurse (RN) license.
- Associate degree in Nursing (ADN) required; BSN preferred.
- Experience in primary care, ambulatory care, care coordination, geriatrics, population health, or a related setting.
- Strong clinical assessment and documentation skills.
- Excellent communication and patient-education skills.
- Ability to work independently and manage multiple priorities.
- Proficiency with electronic medical records (EMR/EHR).
Preferred:
- Experience conducting Medicare Annual Wellness Visits.
- Familiarity with CMS requirements and preventive health measures.
- Experience with population health, quality metrics, or care-gap management.
- Experience working with Medicare and/or older adult populations.
- BSN or additional training in care coordination, population health, or case management.
Ideal Candidate
The successful candidate will be:
- Patient-centered and compassionate.
- Highly organized and detail-oriented.
- Comfortable working independently.
- Strong in clinical assessment and patient education.
- Proactive in identifying gaps in care.
- Comfortable collaborating with providers and multidisciplinary teams.
- Interested in preventive care and improving population health.