MDS Nurse Supervisor

POSITION SUMMARY:
The MDS Coordinator is a skilled healthcare professional responsible for ensuring precise assessment coding and maintaining current care plans for all residents, collaborating with or acting as the RN Coordinator. Through meticulous assessment coding, the MDS Coordinator establishes reimbursement rates for eligible residents and quality metrics for public reporting. This role also guarantees that records related to resident care align with the care plan and accurately reflect the services provided.

KEY RESPONSIBILITIES:

1. Must possess the physical and mental capability to perform routine job functions.

2. Should have a solid understanding of nursing services, administration, rehabilitation, general nursing, geriatric care, the MDS process, and its electronic medical record (EMR) application.

3. Requires strong managerial, organizational, planning, computer, and interpersonal skills.

4. Ability to initiate, contribute to, complete, and update care plans with each MDS assessment within the applicable scope of practice.

5. Capable of conducting in-service training for nursing staff on care plans, documentation, activities of daily living (ADLs), and EMR application.

6. Responsible for monitoring resident EMR records for consistency and content accuracy.

7. Ability to identify issues and communicate them to the Director of Nursing, Social Worker, Activity Director, Diet Tech/RD, or other relevant facility personnel.

8. Must interact positively with residents, families, and staff in a professional and collaborative manner.

9. Should demonstrate compassion, tolerance, and understanding towards the elderly population.

10. Knowledge of IDH standards and documentation methods in accordance with those standards is essential.

11. Must be proficient in navigating the Resident Assessment Instrument (RAI) Manual.

12. Understanding of the technical and clinical criteria necessary for Medicare beneficiary coverage is required.

PRIMARY DUTIES:

A. Uphold the facility's care philosophy and strive to meet its goals and objectives.

B. Oversee the completion of the MDS upon:

a. initial admission

b. readmission

c. quarterly assessments

d. annual reviews

e. significant changes

f. as needed for PPS/Insurance reimbursement

C. Provide a monthly calendar of scheduled MDS assessments. Opening MDS assessments in the EMR allows the interdisciplinary team (IDT) to work from the In-Progress list.

D. Ensure timely completion of each MDS section by the appropriate department, with staff signatures on the EMR, ensuring resident appropriateness.

E. Collaborate with each department to address any issues in their MDS sections and arrange for re-education as necessary, focusing on accurate coding and supportive documentation.

F. Review ICD 10 diagnosis coding and sequencing upon admission, reentry, and each MDS assessment completion, completing Physician Queries for clarification as needed.

G. Conduct daily reviews of clinical records to identify opportunities for capturing the highest level of care on OBRA and PPS assessments, aligning reimbursement with care and resident characteristics.

H. Facilitate daily MDS-therapy meetings and weekly Utilization Review meetings.

I. Participate in pre-billing reviews of claims per facility guidelines.

J. Monitor MDS-based Quality Measures for coding errors and assist the IDT in identifying measures for facility QAPI efforts.

K. Support staff across all departments with EMR charting, documentation, and achieving care plan goals in accordance with the resident's MDS.

L. Communicate resident care plans and progress to staff, residents, and families, ensuring care plan review dates are set in PCC with MDS assessments and that reviews are signed timely by each applicable IDT member.

M. Conduct in-service training for nursing staff every three months as needed on care plans and documentation.

N. Record, report, and follow up on discrepancies in documentation that do not meet program standards.

O. Collaborate closely with the Director of Nursing and other department heads to ensure consistency in resident care.

P. Work with, or as, RN to coordinate resident care plans with therapy departments to ensure appropriate care and treatment when clinically indicated.

Q. Maintain confidentiality of resident information and respect their personal and property rights.

R. Adhere to established fire, disaster, safety, infection control, and evacuation policies and procedures.

S. Perform additional duties as assigned by the Administrator.

T. Assist with staffing coverage as necessary to meet resident needs.

QUALIFICATIONS:

1. A current State of Indiana license as a Registered Nurse or Licensed Practical Nurse is required.

2. Must be able to read, write, and communicate in English effectively.

3. AANAC certification is preferred.

PHYSICAL AND SENSORY REQUIREMENTS:

• Must be able to move intermittently throughout the workday.
• Must be able to communicate effectively in English.
• Must be able to manage the mental and emotional stress associated with the position.
• Must possess adequate sight/hearing senses or use prosthetics to meet the requirements of this position.
• Must function independently, demonstrating flexibility, integrity, and the ability to work effectively with residents and staff.
• Must meet general health requirements set forth by facility policies, including medical and physical examinations.
• Must be able to relate to and work with ill, disabled, elderly, emotionally distressed, and at times hostile individuals.
• Must be able to lift a minimum of 25 pounds to a height of 5 feet and carry such weight a minimum distance of 50 feet.
• May be required to assist in the evacuation of residents during emergencies.

WORKING CONDITIONS:

• Works in office areas and throughout the facility.
• Moves intermittently during working hours.
• Subject to frequent interruptions.
• Engages with residents, personnel, visitors, and government agencies under various conditions.
• May be exposed to varying temperatures in kitchen/storage areas.
• May experience sudden temperature changes when entering refrigeration areas.
• Communicates with medical staff, nursing personnel, and other department directors.
• May work beyond normal hours, including weekends and holidays when necessary.
• Subject to call back during emergencies (severe weather, evacuation, etc.).
• May be at risk of injury from falls, burns, odors, and other hazards throughout the workday.
• May be exposed to infectious waste and diseases, including TB and Hepatitis B viruses.

May involve handling and exposure to hazardous chemicals.

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