Job Code:8 (LPN) or 6 (RN) Department: MDS Nursing 4004

FLSA:Salaried Exempt Generally Reports to: Director of Nursing

The following statements are intended to describe the general nature and level of work being performed and are not intended to be a complete list of all responsibilities, duties and skills required.

SUMMARY

Coordinates assessment data from all disciplines for the RAI process, assuring the timely completion of the MDS process including MDS 3.0 and CATs after evaluating resident’s functional abilities and reviewing data to help the IDT develop a comprehensive, individual, resident-centered plan of care.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Selects appropriate assessment types and set preferred assessment reference dates to ensure the accurate and timely completion of resident assessments according to state and federal regulations.
• Performs strategic assessment scheduling considering Quality Measures Data and optimal revenue through ARD selection for optimal placement within Resource Utilization Groups.
• Works in collaboration with the interdisciplinary team to identify the needs and preferences of the resident and to inform team members of assessment scheduling needs and changes.
• Maintains privacy and confidentiality of records, conditions and other information relating to resident, other employees and the facility.
• Conducts orientation sessions on the MDS process to all employees involved and educates staff about supporting documentation of MDS to help ensure care delivery is accurately coded.
• Delegates responsibility for completion of assessment sections to staff possessing clinical knowledge about the resident such as social work, activities and dietary personnel.
• Interviews relevant staff and analyzes supporting documentation to complete coding for the MDS.
• Monitors documentation in the facility including Skilled Nursing Medicare documentation and reports findings as directed to ensure consistently and compliance with state and federal requirements.
• Ensures physician certifications are completed, signed and dated properly.
• Completes ICD-10 coding.
• Completes MDS assessments and Care Area Trigger Summaries (CATs) and completes corrections when necessary.
• Conceives and participate in the development of the comprehensive care plan reflecting resident’s individual needs and preferences and monitor for necessary revision in between scheduled assessments.
• Assures validation, finalizing and completion of MDS assessments is performed.
• Coordinates the electronic submission of required documentation and reads and follows up on submission validation reports.
• Retrieves and distributes Quality Measure reports monthly and collaborates with others regarding findings as directed by the Administrator.
• Monitors all facility MDS 3.0 assessments and care plans to ensure that they are completed in a timely manner, are completed appropriately, meet state and federal regulation, and meet standards of practice and clinical guidelines.
• Participates in quality assurance programs such as daily PPS meeting, weekly “At-Risk” meeting and UR meetings.
• Participates in care plan conferences with residents and responsible parties.
• Recognize alteration from previous baseline condition to capture significant change in resident condition per regulations to ensure that assessments and care plans are repeated and revised as needed to accurately reflect resident’s abilities, preferences and goals.
• Evaluates and re-evaluates residents’ needs and levels of care by standards and requirements.
• Participates in surveys by authorized government agencies.
• Completes required forms and documents in accordance with company policy and state and/or federal regulations
• Other duties as assigned by the Administrator

ENTRY QUALIFICATIONS

• Graduate of an accredited school of Nursing.
• Valid State registration as an LPN/LVN or RN.
• Knowledgeable of OBRA, Perspective Payment System, and current MDS processes.

SUPERVISORY RESPONSIBILITIES

N/A

PHYSICAL DEMANDS AND ENVIRONMENT

Employee is frequently required to stand, walk, use hands or fingers, reach with hands and arms, feel, talk and hear. Employee will occasionally assist to lift and / or transfer patients weighing between 100 to 250 pounds. Employee may occasionally be exposed to blood or other body fluids. In compliance with applicable law, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

OTHER REQUIREMENTS

Participates in (or conducts) company-sponsored training to safeguard against improper use and disclosure of resident's protected health information. Monitors and ensures compliance with company policies, procedures and state and federal law. By his / her signature below, employee agrees to adhere to and oversee communication of privacy guidelines relative to

the confidentiality of residents' protected health information.