Mds Rn Nurse

Description:

The Case Management Director, RN serves as the team leader for the Case Management team. Conducts and directs the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this facility. Ensures all Case Management staff meet timeliness, completeness, and accuracy demands of MDS, CAAs, and comprehensive care plans. Monitors quality measures and other CMS measures. Assists facility and regional leadership with ensuring that documentation in the facility meets Federal, State, and Certification guidelines.

Essential Functions 

Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

Residents Rights

Knows and respects patient rights. Assures that individuals’ rights are honored, and that care is delivered according to those rights and the individual’s wishes. Ensures patients’ rights, safety, and choices are safeguarded. 
Ensures that care is provided in privacy. 
Ensures protected health information is kept confidential. Reports known or suspected incidents of unauthorized disclosure of such information. 
Reports complaints made by residents/patients to supervisor. 
Reports all allegations of patient abuse, neglect and/or misappropriation of patient property. 

Safety and Sanitation

Follows established safety policies and procedures. 
Follows established infection control policies and ensures compliance amongst staff. 
Observes safety needs of patients as indicated in care plan and ensures staff do the same. 
Wears and/or uses safety equipment and supplies when indicated and properly trained to use. 
Demonstrates job-specific knowledge of fire and disaster preparedness during drills or actual situations. 

Staff Development

Attends, provides, and participates in scheduled in-service training, educational classes, and meetings to maintain current licensure and certification as applicable and as managed by regulatory agencies and company policies. 
Provides staff training re: documentation, ADL’s, restorative services, and other topics. 
Ensures team members can follow RAI processes. 
Trains new Case Management staff. 
Completes assigned Relias training. 

Regulatory and Certification Responsibilities

Assists the facility in assuring adherence to Federal and State regulations and certification. 
Actively participates in the regulatory or certification survey process and correction of deficiencies as requested. 
Speaks to surveyors calmly and clearly regarding MDS and care planning. 
Monitors/audits documentation, ADL’s, care plan implementation. Reports trends to supervisor and department heads as requested. Directs Case Management staff in completing audits and monitoring tasks. 
Reports trends from completed audits to the QA committee as directed by the Executive Director and/or the Director of Health Services. 

RAI-MDS, CAAs, Care Plan Responsibilities

Assures the completion of the RAI Process from the MDS through the interdisciplinary completion of the plan of care. 
Initiates and monitors RAI process tracking, discharge/reentry, and Medicaid tracking forms through the Electronic Health Record (E.H.R.). 
Follows up with staff when necessary to assure compliance to standards of documentation. 
Conducts and coordinates patient assessments, data collection, and interviews staff as necessary to assure good standard of practice and as instructed in the current version of RAI Manual and company policies. 
Transmits, or oversees this function, of managing the MDS data in compliance with state and federal rules and regulations. 
Facilitates accurate determination of the Assessment Reference Date that accurately reflects the patient’s care needs and captures all resources utilized to ensure appropriate payment by Medicare/Medicaid and insurance programs. 
Provides interdisciplinary schedules for all MDS assessments and care plans as required by OBRA and PPS regulations. 
Assures that appropriate signatures are obtained as required. 
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. 
Assists Director of Health Services or designee with identification of a significant change. 
Reviews physician orders and verbal reports to assure that the MDS and care plan are reflective of those changes. 
In conjunction with Social Services, coordinates scheduling and notices of patient care planning conferences and assures communication of outcomes/problems to the responsible staff, patient, and/or responsible party. 
Ensures all MDS information and care delivered as outlined in the Care Plan is supported by documentation. 
Works with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident. 
Assist the Executive Director/Director of Health Services with the monitoring to ensure that a care plan is initiated on every patient upon admission to the facility. 
Participates in the daily stand-up meeting and communicates needs for changes in PPS timelines and Assessment Reference Dates, and deficiencies in completion of MDS, CAAs, and Care Plans. 
Relays and/or acts upon information from the Case-Mix Specialist audits. 
Acts as resource person for computer issues that relate to the MDS process. Contacts the help desk when indicated. 
Responsible for ensuring appropriate Medicare coverage through regular communications with consultants. 
Attends daily and weekly Medicare or Utilization Review meetings as required. 
Corrects and ensures completion of final MDS and submits patient assessment data to the appropriate State and Federal government agencies. 
Assigns, assists, and instructs all staff in the RAI Process, PPS Medicare, Medicaid (Case Mix as required) and clinical computer system in relation to these processes. 
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. 
Ensures that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification. 
Ensures that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs as identified in the resident’s assessment. 
Assist the Director of Health Services and relevant directors/supervisors of other departments in ensuring that personnel involved in providing care to the resident are aware of the resident’s care plan availability. 
Ensures the physician certification/recertification is completed as required. 

Supervisory/People Management Responsibilities

Assists in planning, coordinating, and conducting continuing education programs and special in-service training sessions relevant to the needs of department personnel. 
Ensures that employees are adequately oriented and trained to perform their duties. 
Reviews employee performance annually and makes recommendations as requested by the Executive Director. 
Participates in interviews as requested by consultant and/or Executive Director. 

Administrative Responsibilities

Participates in staff meetings, department meetings, and other facility meetings and sits of required committees. 
Performs administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary. 
Develops, implements, and maintains an ongoing quality assurance program for the resident assessment/ care plans. 
Assists the resident and Social Services in completing the care plan portion of the resident’s discharge plan. Participates in functions involving discharge plans as may be necessary. 
Monitors the facility’s QI, QM, and Five-star reports to ensure that appropriate corrective action can be implemented when potential problems areas occur. 
Coordinates with therapies -- Occupational, Physical and Speech - regarding resident rehabilitation. 
Ensures that a current copy of the RAI Manual is available. 
Agrees not to disclose assigned user ID code and password for accessing resident/facility information and promptly reports suspected or known violations of such disclosure to the Executive Director. 
Assists with admission, discharge, transfer, medication administration and/or treatments according to practice act as determined by the Executive Director in crisis situations. 
Performs any miscellaneous work assignments as may be required. 
Education/Qualifications 
Graduate of an approved Registered Nurse program and licensed in the state facility is located is required. 
MDS certification (RAC-CT/CTA, CMAC) preferred. Willing to complete within 1 year of hire. 
Current CPR certification. 
Must be knowledgeable of nursing and medical practices and procedures, as well as MDS processes and the laws, regulations, and guidelines that pertain to nursing care facilities. 
Demonstrates strong organizational, critical thinking, and analytical skills. Attention to detail a must. 
Must be able to read, write, speak, and understand the English language. 
Thinks and acts calmly and logically to meet unusual occurrences of the job without being thrown off stride. 
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the public. 
Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel. Demonstrates integrity in their work. 
Persons who have been found guilty by a court of law of misappropriation, forgery, fraud, or theft are ineligible for this position. 
Persons who have been found guilty by a court of law or identified in by any registry or licensing body of abusing, neglecting, or mistreating individuals in a health care related setting are ineligible for employment in the position. 
Experience 
Minimum of two (2) years of nursing experience in a Skilled Nursing Facility required. 
Minimum of one (1) year of experience in MDS. 
Excellent knowledge of Case-Mix, the Federal Medicare PPS process, and Medicaid reimbursement, is required. Proficient with PDPM. Thorough understanding of Quality Indicators and Quality Measures. Understands, can teach, and can cite OBRA and Minimum Data Set (MDS) guidelines as needed. Thorough knowledge of the care planning process. 
Physical Demands 
Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet; Walking, standing, pushing, climbing, balancing, stooping, kneeling, crouching, reaching, handling, fingering, feeling, talking, hearing, tasting, smelling, near acuity, far acuity, depth perception, accommodation, color vision are necessary for this position. 
This position requires extensive use of office equipment including computers, phones, fax, scanner, etc. Repeating motions that may include the wrists, hands and/or fingers. Will be sitting for extended periods.