MDS Nurse/ RN

Purpose of Your Job Position

The MDS Nurse is responsible for completion of Minimum Data Sets (MDS) and associated processes in the development of the individualized plan of care and the appropriate financial reimbursement for each patient.

Delegation of Authority  

As a MDS Nurse, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. 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 an essential function of the position

Duties and Responsibilities

Administrative Functions

Ensures the completion of the Minimum Data Sets (MDS) and Plan of Care in an accurate and timely manner, in accordance with Nursing Department policies and procedures, State and Federal requirements, and following the established interdisciplinary process.
Adheres to the schedule for completion of the MDS.
Ensures the timely completion of the MDS process in accordance with OBRA and PPS regulations.

Completes designated nursing sections of MDS, reviews the MDS for completion, and transmits MDS to the state.

Completes the CAA summary, CAA notes, Medicare Assessment tracking form, discharge, and re-entry tracking forms, as applicable;
Gathers pertinent information regarding patients/residents from personal observations, discussions with nursing staff, patient/resident family members, other members of the interdisciplinary team, etc., and ensures all information is included in the MDS;
Coordinates managed care updates and seeks highest reimbursement, as directed;
Provides assistance to the UR team during MDS reviews, as directed;
Facilitates weekly Medicare meetings, PPS, participates in committees/action plans to further develop the care planning process, and attends all other meetings as directed to assess the need for patient/resident significant changes.

Serves as an educator regarding MDS information, ADL coding, skilled documentation, and all discipline documentation needed for MDS.

Serves as an active and visible member on each unit, and as a resource, observer, and listener to obtain an accurate picture of each patient/resident’s care status.

Participates in regularly scheduled reviews of the discharge plans and makes such plans available to the Care Plan Committee as required or as may be necessary.

Assists in ensuring compliance with State and Federal standards and regulations.

Interacts regularly with Director of Nursing, Nursing Department staff, etc., to develop and monitor indicators to assess the effectiveness of the care planning process.

Effectively collaborates with all staff members, clinical care, and interdisciplinary team members to work towards the provision of maximum quality care for patients/residents.

Follows all established departmental policies and procedures at all times;

Performs other duties as assigned or as necessary.

Remains flexible and adaptable in work schedules and work assignments as defined by departmental and organizational needs.

Committee Functions

Attend various committees of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Budget, Quality Assurance & Assessment, etc.) as required.

Serve on the Quality Assurance and Assessment (QA) and Quality Assurance and Performance Improvement (QAPI) Committees as directed.

Serves on the Compliance and Ethics Committee

Provide information to the QA and QAPI Committees as requested

Assist in preparing written and/or oral reports of MDS programs and activities to submit to such committee(s) as directed.

Participate in developing the agenda for the Care Plan Committee meetings as necessary.

Participate in regularly scheduled reviews of the discharge plans and makes such plans available to the Care Plan Committee as required or as may be necessary.

Implements recommendations from established committees as instructed by the Director of Nursing.

Attends all other meetings as necessary or as directed.

Resident Rights

Maintain the confidentiality of all resident care information.

Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect.

Promote resident rights and responsibilities, including the right to refuse treatment.

Report complaints or grievances made by the resident to the Director of Nursing and/or grievance coordinator in accordance with the facility's established procedures.

Report all allegations of resident abuse, neglect, mistreatment and/or misappropriation of resident property and follow facility policies on Abuse Prohibition.

Working Conditions

Works in office area(s) as well as throughout the nursing service area (i.e., dining rooms, nurses' stations, resident rooms, etc.).

Moves intermittently during work hours;

Is subject to frequent interruptions.

ls involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

ls subject to hostile and emotionally upset residents, family members, personnel, and visitors.

Communicates with the medical staff, nursing personnel, and other department supervisors.

Works beyond normal working hours, weekends and holidays when necessary.

Is subject to call-back during emergency conditions (e.g. severe weather, evacuation, post-disaster, etc.).

Is involved in community, civic health matters, and projects as appropriate.

Attends and participates in continuing educational programs.

Is subject to injury from falls, burns from equipment, odors, assaults from hostile residents, etc. throughout the work day, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

May be subject to the handling of and exposure to hazardous chemicals.

Maintains, and acts as a liaison with the residents, their families, support departments, etc., to adequately plan for the residents' needs.

Education Requirements

Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an accredited Nursing program as a Registered Nurse (RN).  

Experience

At least one (1) year of experience in MDS coding

Minimum of two (2) to four (4) years of experience working in a Long Term Care Center  

Specific Requirements

Must posses and maintain a current, unencumbered, active license to practice as a Registered Nurse or Licensed Practical Nurse in this state.

Must possess and maintain a current “Eligible’ AHCA Background Screening Status

RAC-CT 3.0 preferred

Knowledge of rehabilitation and restorative care required

Effective communication, interpersonal, and organization skills required

Computer proficiency required

Experience with computerized MDS system and current MDS/RAI guidelines required

Knowledge of the Matrix system is preferred.

Must speak and understand English

Must possess the ability to make independent decisions when circumstances warrant such action.

Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.

Must possess ability and the willingness to work harmoniously with other personnel.

Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc. that are necessary for providing quality care.

Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

Must be able to relate information concerning a resident's condition.

Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

Must be able to move intermittently throughout the work day.

Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position.

Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.

Must function independently, have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.

Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.

Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people within the facility.

Must be able to push, pull, move, and/or lift a minimum of 35 lbs. to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 450 feet.

May be necessary to assist in the evacuation of residents during emergency situations.