Clinical Assessment Nurse
2 weeks ago
GENERAL OVERVIEW:
The Clinical Assessment Nurse plays a vital role in gathering and evaluating data related to the health and wellness of residents in Medicare or Medicaid-certified facilities. This position adheres to both Federal and State regulations concerning all sections of the Minimum Data Set (MDS). The Clinical Assessment Nurse is responsible for monitoring the health status of residents from admission through discharge, contributing to Quality Assurance initiatives and quality measures.
KEY RESPONSIBILITIES:
(This list is not exhaustive and may include other duties as assigned.)
1. Completes nursing components of the Resident Assessment Instrument (RAI) process to ensure timely submission of the Minimum Data Set.
2. Ensures that PPS and/or OBRA assessments are completed for both subacute and long-term care as mandated.
3. Collaborates with residents, families, advocates, and interdisciplinary team members, including healthcare providers, to ensure that each resident receives optimal care for the best possible quality of life.
4. Utilizes independent judgment in planning, organizing, directing, and evaluating the activities of nursing staff involved in resident care planning.
5. Applies State and Federal guidelines for the RAI process, ensuring that documentation meets necessary standards for compliance and reimbursement.
6. Signs off on MDS forms to confirm the completion of the assessment process.7. Reviews the accuracy of MDS responses across all disciplines.
8. Ensures timely and precise completion of MDS assessments.
9. Works alongside the Health Information Management Director and Quality Care Coordinator to conduct concurrent MDS reviews, aiming for maximum allowable RUG categories.
10. Collects information from nursing, dietary, social services, therapy, and physician services to guarantee appropriate quality of care and reimbursement.11. Performs additional tasks as directed by the Director of Health Information.
12. As necessary, assists in completing nursing assessments and developing comprehensive care plans for residents, identifying their needs, care provided, goals, and responsible professional services.
13. Ensures legal compliance for the facility by adhering to the MDS process.14. Aids in determining coverage for skilled nursing services and provides comprehensive documentation to prevent payment denials.
15. Utilizes RAI, MDS 3.0, QM, and QRP manuals to ensure the highest quality of care, supporting documentation for outcomes, and maximizing reimbursement.
16. Reviews 24-hour reports for updates and potential changes in resident conditions.17. Assists with the Quality Assurance Program as required.
REQUIREMENTS:
- Current NYS Licensed Registered Nurse
- Familiarity with MDS 3.0, CAA's, and Medicare and Medicaid guidelines for coverage and reimbursement
- Strong written and verbal communication skills, with the ability to work independently under pressure
- Experience in Long-Term Care is beneficial but not mandatory.
- Basic computer proficiency is required.
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