OBJECTIVE:

To evaluate residents for appropriate services and maintain appropriate documentation. To coordinate the accurate, timely documentation of all resident assessments (RAI) to ensure quality resident care reflected in the plan of care. To direct the interdisciplinary care planning team. To coordinate computer input of MDS and Care Planning, and electronic submission to the State.

RESPONSIBILITIES:

1. Review all new admissions for potential CMI including monitoring for medicare and coordinate room changes with Director of Nursing, Social Services, Admissions/Discharge Coordinator to determine level of care; complete required MC/MA certification for physician’s signature regularly.

2. Completes routine medical record review (MRR) audits for accuracy and compliance.

3. Utilizes RAI Manual for adherence to regulatory compliance and best practices.

4. Maintain master care planning schedule and oversee the ongoing assessment of residents’ Care Planning in conjunction with other disciplines to ensure that care plans are developed to meet resident needs/goals in correlation with MDS and Resident Assessment Protocols; lead Care Plan Meetings. Ensure that all care plans are reflective of care needs of residents and reflect MDS and updated ICD10 coding as needed.

5. Responsible for leading Morning Meeting to ensure appropriate timing of Medicare eligibility and planning discharge of residents. Ensure accuracy of documentation.

6. Coordinate and assist with input of MDS and Care Plan on computers. Coordinate and send electronic transmission to State as required by State. Ensure accuracy of data transmitted.

7. Assist to inservice computer system for resident records, MDS, Administration information, Care Planning to interdisciplinary team, nursing staff on all shifts.

8. Monitor documentation in charts to be reflective of resident care needs for significant changes, care planning changes, and psychotropic medication. Ensure timeliness of all departments through appropriate procedures.

9. Supervise completion of LPN assessments to ensure accurate and timely completion.

10. Assign assessment responsibilities to LPN floor nurses per shift, based on the MDS schedule.

11. Monitor case mix index to ensure highest possible CMI for the facility. Implement needed changes to increase CMI. Keep DON informed of any concerns, problems.

12. Prepare appropriate reports and maintain records ie: Care Plan schedule, MDS schedule and additions, Medicare and Medical assistance forms, Quality improvement reports, etc.

13. Attend QA&A meetings as required by DON.

14. Keep DON informed of any concerns related to this position.

15. Act per chain of command for coverage of DON in her absence or absence of Administrator.

16. Responsible to stay informed of regulatory statutes and changes as related to MDS, Medicare, Medical Assistance and LTC.

17. Continually update knowledge base of data entry and technology.

18. Consult with Case Manager on authorizations and reviews all other documentation.

19. Implement and maintain Triple Check system and work with Finance, Therapy and other stakeholders.

20. Coordinate responsibilities with other NAC team members and cross train to provide backup.

21. Monitor daily ADL competition and accurate documentation and provide education to responsible staff, recommending corrective action if necessary.

22. Collaborate with special nurses regarding areas of potential…..

23. May need to cover as RN supervisor.

24. Other duties as assigned.

WORKING CONDITIONS:

1. Work in well-lighted/ventilated halls and rooms.

2. Possibility of cuts or minor burns from instruments and equipment.

3. May be exposed to communicable diseases.

4. Possibility of strains due to moving residents or injury from irrational residents.

5. Sits, stands, and walks most of working day.

6. Maybe subject to electrical and/or mechanical hazards.

7. May have to perform duties of RN Supervisor, LPN and NA staff to promote teamwork and to maintain familiarity with these roles.

PHYSICAL DEMANDS:

1. Good physical and mental health.

2. Finger and hand dexterity to handle and manipulate instruments and equipment including data entry on a daily basis and sometimes mass data updates.

3. Must be able to withstand strenuous physical activity, such as lifting/turning residents, pushing wheelchairs, med carts and other equipment.

4. Visual and aural acuity to detect changes in resident’s condition. Constant standing and walking during work period. Must be able to work with standard computer monitor.

EDUCATION AND EXPERIENCE:

1. Graduate from an accredited school of nursing.

2. Must possess 3-5 years in the area of education, management skills, supervision and clinical experience.

3. Possess a license as a Registered Nurse issued by the PA State Board of Nursing Education and Licensure.

4. Must be self motivated with initiative to learn and implement needed programs.

5. Must have ability to plan, implement, delegate, and supervise the work of others.

6. Must have ability, personality, and communication skills to assume cooperation from other staff members and communicate with all levels of the Organization.

7. Must be able to problem solve and prioritize many aspects of position.

8. Must have desire to learn or possess computer knowledge and experience.

9. Must have ability to learn, apply learning and teach what is learned.

10. Must be certified in CPR.

11. Flexible to change schedule, work weekends, evenings as needed to complete duties.

12. RAC-CT certification preferred or willingness to become certified within 3 years.