MDS RAI Coordinator RN - SAU FT Days

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

Responsible for the SAU’s RAI (Patient Assessment Instrument) process, including timely scheduling, completion of MDS assessments, Care Area Assessments (CAAs), CAA Summary and Care Plans.  Ensures that the SAU is in compliance with all applicable state and federal regulations and insurance requirements, related to the completion of the RAI process.

Essential Functions

• Manages oversight of accurate and timely scheduling and completion of MDS assessment process, including OBRA, Medicare, managed care and/or Medicaid assessments, according to applicable rules and regulations.  
• Accurately completes the MDS assessments, Care Assessment Areas (CAAs), CAA Summary and Care Plans as required within regulatory guidelines and state nursing practice act. Performs patient interviews and patient observations, collaborates on data collection and verification with members of the interdisciplinary team, and thoroughly reviews the medical record to obtain the most accurate picture of the patient’s status and performance during the assessment reference period.  
• Oversees the input of MDS assessment data into myUnity, the transmission of completed assessments to the QIES ASAP database, validation of MDS acceptance and uploads of MDS information and assessments into myUnity.
• Monitors to ensure accuracy of MDS assessment data in relation to the impact on billing and reimbursement, including PPS/PDPM, managed care contracts and Medicaid case mix.
• Performs quality control audits for assessment accuracy, monitors for timeliness and completeness, documents problems as they relate to clinical issues pertaining to the medical record and communicates findings to appropriate personnel.
• Documents the patient’s condition and nursing needs accurately and in a timely manner.  Reports pertinent observations and reactions regarding patients promptly to supervisor(s) and physician as indicated.
• Participates in counseling, disciplinary action and termination of staff to the extent permitted by state practice act.
• Assures compliance with policies and procedures. Reports problems and complaints timely to the Nurse Manager.
• Participates in hiring, selection, and orientation of RNs, LPN/LVNs and Nurse Aides as requested.
• Gives feedback and participates in performance appraisals as assigned.
• Maintains positive working relationships between nursing and other departments.
• Supports and participates in the center’s Performance Improvement initiatives.
• Monitors the Quality Indicators and Quality Measures within the SAU and works with the nursing team to establish clinically appropriate Performance Improvement plans.
• Participates in survey readiness per facility guidelines and as directed.
• Adheres to professional codes of ethics and Kindred’s Code of Conduct.  Maintains PHI confidentiality in the center and in external locations, including electronic social networks.
• Initiates, recommends, communicates, and implements changes in patient’s care plans. Assists with or institutes emergency measures for sudden adverse developments in patients.  Directs and administers cardiopulmonary resuscitation.
• Documents care performed and observations of patient status in the clinical record promptly by utilizing standard clinical documentation guidelines as required by Kindred, and local, state, and federal rules and regulations. Monitors completeness and accuracy of own medical record entries.
• Demonstrates working knowledge and application of ICD coding, with ongoing efforts to keep current with regulatory and reimbursement changes.
• Assures patients preferences and advanced directives are respected.
• Educates appropriate staff on state specific MDS related documentation requirements.  Communicates educational needs of staff-to-staff development coordinator and supervisors. Provides individual and/or unit education to patients, families, and staff based upon need and within scope of practice.
• Demonstrates critical thinking skills, including the ability to synthesize information and make role-appropriate decisions.
• Shows initiative in meeting patients’ needs and addressing problems.
• Demonstrates a positive attitude, communicates effectively and actively listens, and functions effectively as part of a team.
• Responsible for timely completion of center-designated competencies in required timeframes.
• Performs other tasks as assigned.

Knowledge/Skills/Abilities/Expectations

• Work efforts reflect a passion for exceeding customer expectations.
• Solicits patient/patient feedback to understand their needs and the needs of the community.  
• Advocates for Service Excellence within the SAU and influences others to take action.
• Displays responsibility by taking ownership of quality care.  
• Shows dedication to enriching the lives of our patients and patients through empathy and compassion.
• Exhibits a commitment to results by looking for and recommending/implementing process improvements.
• Demonstrates commitment to interpersonal excellence through professional greetings, proper telephone etiquette, common courtesy, a professional attitude, and appearance.
• Enriches the SAU culture by having fun.
• Recognizes the benefits of team collaboration.  Shows respect for fellow employees by working together to get the job done.
• Effectively addresses customer concerns and resolves conflict in a manner that is fair to all.
• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Approximate percent of time required to travel:   0-10%
• Performs other duties as assigned.

Education      

• Graduate of an accredited school of nursing – RN required.

Licenses/Certification     

• Current RN licensure in the state employed.
• BLS Certification

Experience      

• At least two (2) years of nursing experience within a post-acute/rehabilitation/long-term care setting is preferred.
• At least one (1) year of /MDS experience preferred.