Overview

The Annual Wellness Visit (AWV) Nurse plays a key role in supporting preventive care and population health initiatives within the primary care setting. Working collaboratively with the primary care team, as well as members of the care delivery and population health teams, the AWV Nurse is responsible for identifying patients eligible for Annual Wellness Visits and independently completing these comprehensive assessments.

 

In this role, the nurse conducts the full Annual Wellness Visit efficiently and thoroughly, focusing on preventive health, patient education, and early identification of risk factors. The AWV Nurse provides guidance on wellness and prevention strategies, connects patients with appropriate care coordination resources, and leverages community programs to promote overall health and reduce avoidable hospital readmissions and unnecessary emergency department visits.

 

This position is ideal for a proactive, detail‑oriented nurse who is passionate about preventive care, patient engagement, and improving outcomes across diverse patient populations.

 

Responsibilities

• Annual Wellness Visit (AWV) Delivery

  • Follow all AWV protocols and standing orders, including completing required preventive services.
  • Independently conduct comprehensive Annual Wellness Visits for eligible patients.
  • Develop and maintain knowledge of AWV eligibility criteria and documentation requirements.
  • Build expertise in Medicare preventive services and clinical guideline recommendations.

  Quality Measures & Documentation

  • Identify and address open quality gaps with patients, working collaboratively toward closure of those gaps.
  • Document care accurately in the electronic health record (EHR) to reflect completed preventive measures and closed gaps.
  • Complete patient encounter forms at the conclusion of each visit.
  • Report outstanding, abnormal, or urgent findings to the provider immediately.

  Collaboration & Workflow Support

  • Work collaboratively with clinical teams to deliver AWVs efficiently for both patients and staff.
  • Support scheduling efforts, including filling open appointment slots, to meet AWV volume goals.
  • Refer appropriate patients to care coordination resources to improve health outcomes.

  Patient Education & Communication

  • Identify patient education needs and provide guidance on preventive care, wellness, and treatment plans.
  • Communicate clearly and compassionately to engage patients in achieving their health goals.

  Administrative & Compliance Responsibilities

  • Maintain accurate and organized patient treatment records and documentation.
  • Comply with HIPAA and all confidentiality standards.
  • Maintain patient, team member, and employer confidentiality.
  • Perform all other duties as assigned within the scope of the role

Qualifications

• Required: Two (2) or more years clinical nursing experience with 1 year in an outpatient setting. Experience with Medicare Annual Wellness Visits as well EHR experience.
• Ability to work independently and exercise sound clinical judgment when interacting with physicians, payors, patients, and families
• Strong ability to prioritize multiple tasks and responsibilities effectively.
• Proficient in computer use and electronic medical records.

Credentials

• Active RN License - State of Delaware or Compact State 
• BLS - Basic Life Support (AHA) 

Education

• Graduate of an accredited nursing school 
• Bachelor's degree preferred

EntryUSD $38.00/Hr. MaxUSD $62.70/Hr.