Job Description

Responsibilities/Duties:

• Utilizes the nursing process to deliver safe and effective patient, resident or tenant centered care without constant supervision.
• Conducts an individualized patient, resident or tenant assessment, prioritizing the data collection based on the patient’s immediate condition or needs within timeframe specified by facility’s policies, procedures or protocols.
• Utilizes interdisciplinary team resources to develop and revise an individualized plan of care, and reprioritizes care accordingly.
• Incorporates cultural/ ethnic/religious/ spiritual preferences, growth and developmental stage characteristics and evidenced based nursing principles into the individualized plan whenever possible.
• Performs appropriate treatments as ordered by physician in an accurate and timely manner.
• Documents patient, resident or tenant assessment findings, physical/psychosocial responses to nursing intervention and progress towards problem resolution.
• Initiates emergency resuscitative measures according to resuscitation and advanced life support protocols.
• Maintains confidentiality in matters related to patient, resident or tenant, family and staff.
• Utilizes SBAR to Report patient, resident or tenant condition to appropriate personnel during each shift.
• Assist other staff nurses by being a resource, by kindly providing education and coaching, assisting them with Physician rounding and orders, teaching and promoting facility goals and events by being a role model.
• Assist the Director of Nursing in identifying, implementing, and evaluating processes for improvement.
• Coordinate and complete MDS assessments in accordance with CMS, state, and facility requirements, ensuring timely submission, assessment accuracy, and compliance with scheduling requirements.
• Review clinical documentation, conduct resident assessments and interviews, and maintain accurate records to support appropriate coding, reimbursement, and regulatory compliance.
• Lead the interdisciplinary care planning process by developing, updating, and evaluating resident care plans, while encouraging resident and family participation.
• Triple check.
• ARD.
• Medicare.
• Attend reimbursement and Medicare meetings.
• Monitor documentation, case mix, reimbursement data, and managed care requirements to support reimbursement accuracy and compliance with Medicare, Medicaid, and other regulatory standards.
• Conduct chart audits, identify documentation deficiencies, and collaborate with department leaders to implement corrective actions and process improvements.
• Participate in regulatory surveys, Quality Assurance and Performance Improvement (QAPI) initiatives, and quality measure reviews to support clinical outcomes and compliance.
• Serve as a resource to staff and interdisciplinary team members by providing education, guidance, and support related to assessment processes, documentation standards, reimbursement requirements, and regulatory expectations.
• Communicate effectively with residents, families, physicians, leadership, and interdisciplinary team members, including leading care conferences as assigned.

Education/Experience:

• Current WI Registered RN
• Associates Degree in Nursing Required
• BLS Required prior to providing direct patient care
• A bachelor's degree in Nursing preferred
• Minimum of 1-3 years of skilled nursing or long-term care experience.
• Previous MDS Coordinator experience preferred.
• Completion of MDS certification within 6 months of hire.
• Experience with Medicare, Medicaid, PDPM, and case management practices preferred.

Professional Skills & Expectations:

• Excellent verbal and written communication skills.
• Exhibit ability to deal with difficult situations demonstrating good judgment and tactfulness, while remaining professional and courteous.
• Represents the organization in a positive and professional manner.
• Strong analytical and problem-solving skills.
• Ability to function well in a high-paced and at times stressful environment.
• Critical thinking and problem solving.
• Abides by STAR Standards.
• Professionalism and strong work ethic.
• Maintain patient confidentiality and adhere to HIPPA policy.
• Contributes to organizational mission and goals.
• Participates in survey readiness and regulatory compliance.
• Thorough knowledge of MDS 3.0 and RAI process.
• Understanding of PDPM reimbursement methodology.
• Strong assessment, clinical, and critical thinking skills.
• Excellent organizational and time management abilities.
• Proficiency with electronic medical records and MDS software applications.
• Frequent use of computers and electronic documentation systems.
• Assist with on call rotation.

Physical Requirements & Environmental Conditions:

• Ability to sit, stand, walk, bend, and reach throughout the workday.
• Ascending or descending step ladders, stairs, and the like.
• Occasionally Moving self in different positions to accomplish tasks in various environments including tight and confined spaces.
• Occasionally Remaining in a stationary position, often standing or sitting for prolonged periods.
• Moving about to accomplish tasks or moving from one worksite to another.
• Adjusting or moving objects up to 25 pounds in all directions.
• Communicating with others to exchange information.
• Repeating motions that may include the wrists, hands and/or fingers.
• Assessing the accuracy, neatness and thoroughness of the work assigned.
• Sedentary work that primarily involves sitting/standing.
• moving objects up to 20 pounds.
• moving objects up to 50 pounds.
• moving objects up to 100 pounds or more.
• Ability to wear personal protective gear as needed