Position Description
Responsible for timely and accurate completion of both the RAI process and care management process from admission to discharge in accordance with company policy and procedures, and Federal, State and Certification guidelines, and all other entities as appropriate- Minimum Data Set, discharge and admission tracking, etc. With direction from the Director of Nursing and VP of Clinical Reimbursement, may coordinate information systems operations and education for the clinical department.
Principal Responsibilities
• Works in collaboration with the Interdisciplinary Team to assess the needs of the resident; Provides interdisciplinary schedule for MDS assessments and care plan reviews as required by governing agencies.
• Ensures that the Interdisciplinary team makes decisions for either completing or not completing additional MDS, assessments based on clinical criteria as identified in the most recent version of the RAI User’s Manual.
• Assist with coordination and management of the daily stand up meeting, to include review of resident care and the setting of the assessment reference date(s).
• Complies with federal and state regulations regarding completion and coordination of the RAI process.
• Monitors MDS and care plan documentation for all residents; ensures documentation is present in the medical record to support MDS coding.
• Maintains current MDS status of assigned residents according to state and federal guidelines.
• Maintains the frequent and accurate data entry of resident information into appropriate computerized MDS programs.
• Completes accurate coding of the MDS with information obtained via medical record review as well as observation and interview with facility staff, resident, and family members.
• Attends interdisciplinary team meeting, quality assurance and other meeting to gather information, communicate changes, and maintain and update records.
• Assists DON or designee with identification of a significant change, physician orders and verbal reports to assure that the MDS and care plan are reflective of those changes.
• Prepares scheduling, notice of resident care planning conferences, and assists DON in communication of outcomes/problems to the responsible staff, resident, and/or responsible party.
• Continually updating knowledge base related to data entry and computer technology.
• Completes electronic submission of required documentation to the state database and other entities per company policy.
• Ensures timely submission of the MDSs to the State with proper follow-up on validation errors. Maintains validation records from the submission process in a systematic and orderly fashion.
• Actively participates in the regulatory or certification survey process and the correction of deficiencies.
• Reports trends from completed audits to the Quality Assurance Committee.
• Assures the completion and timeliness of the RAI Process from the MDS through the completion of the plan of care.
• Initiates and monitors RAI process tracking, discharge/reentry, and Medicaid tracking forms through the Point Click Care system.
• Follows up with staff when necessary to assure compliance to standards of documentation; Ensures MDS assessments and care delivered as outlined in the Care Plan is supported by documentation.
• Conducts or coordinates physically each assessment and interviews staff as necessary to assure good standard of practice and as instructed in the current version of MDS User’s Manual.
• Facilitates accurate determination of the Assessment Reference Date that accurately reflects the resident’s care needs and captures all resources utilized to ensure appropriate payment by Medicare/Medicaid and insurance programs.
• Assures that appropriate signatures are obtained from individuals completing specific portions of the MDS.
• Sign and certifies assessments are complete.
• Evaluates the need for significant change assessments utilizing current RAI manual criteria.
• Coordinates scheduling and notice of resident care planning conferences with notification to the responsible staff, resident, and/or responsible party.
• Assist the Administrator/Director of Nursing with the monitoring to ensure that a care plan is initiated on every resident upon admission to the center.
• Relays and/or acts upon information from Case-Mix Specialist audits. Job Description Manual Revised December 2023
• Attends weekly Medicare, Medicaid and Managed Care meetings as required.
• Corrects and ensures completion of final MDS and submits resident assessment data to the appropriate State and Federal government agencies.
• Assigns, assists, and instructs staff in the RAI Process, PPS Medicare, Medicaid (Case Mix as required) and clinical computer system in relation to these processes.
• Maintains confidentiality of necessary information.
• Other duties, responsibilities and activities may change or assigned at any time with or without notice.
General Responsibilities
• Attends and participates in scheduled training, educational classes, and meetings to maintain current certification as applicable; Attends and participates in in-service training as mandated by regulatory agencies and company policy.
• Adheres to work schedules in completing and performing assigned tasks; completes all assigned tasks in a timely manner as instructed by the direct supervisor.
• Meets acceptable center attendance requirements; notifies facility before late arrival to or absence from work according to established center policy.
• Cooperates with other facility personnel to ensure that services can be adequately maintained to meet the needs of residents; creates and maintains an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment.
• Adheres to established employee policies.
• Adheres to established dress code.
Qualifications
• Graduate of an approved Registered Nurse program and licensed in the state of practice, required.
• Minimum of 2 years of nursing experience in a Skilled Nursing Facility preferred.
• Excellent knowledge of Case-Mix, the Federal Medicare PPS process, and Medicaid reimbursement, as required.
• Thorough understanding of the Quality Indicator process. Knowledge of the OBRA regulations and Minimum Data Set.
• Knowledge of the care planning process.
• Experience with MDS 3.0, preferred.