Assessment and Care Plan Coordinator

Position Purpose

To facilitate the Resident Assessment Instrument (RAI) communication process with contract consultant.  To lead along with consultant efforts to ensure the highest level of regulatory compliance and reimbursement within the skilled nursing facility in accordance with Brewster Place’s philosophy of care and approved policies.  To continuously monitor the elders’ medical conditions and direct the necessary resources to achieve the highest level of health status and functional capability.

Key Responsibilities/Duties

Ensures, timely and accurately, the Minimum Data Set (MDS) comprehensive assessment instrument.  Coordinates compliance with all applicable Medicare regulations and guidelines to ensure the greatest level of reimbursement for clinical services provided through the Medicare program.

Leads the multi-disciplinary effort of developing and reviewing residents’ plan of care, including all interim, or admission, plans of care are in place at the time of admission.  Ensures that all residents have an accurate and current plan of care that addresses the physical, cognitive, social and spiritual needs of our residents.

Conducts regular rounds to monitor and assess residents’ ever-changing physical, cognitive, social and spiritual status, and to monitor the accuracy of both MDS assessments and care plans.

Monitors Medicare documentation and communicates problem areas to the Director of Nursing.

Involved in the determination of Medicare skilled coverage on all inquiries.

Part of the interdisciplinary team that discusses section GG at the end of stand up to confirm information for MDS completion.  

Facilitates the completion of all care plans within BHC.  Ensure they are person-centered. 

Leads the care plan meetings for Long term Care and attends Family Goal Meetings for Rehab to ensure plan is captured in the written care plan.

Audits baseline care plans

Participate in on-call rotation per policy & procedure

Other duties as assigned

The most significant duties have been included in this description.  This does not preclude the assignment of occasional additional or developmental duties.  The organization reserves the right to modify this job description as needed to accurately reflect duties assigned.

Education:

Associate Degree preferred, LPN licensure accepted

Experience:

3-4 years

Certification:

RN in good standing and currently licensed in KS

Any preferred education/skills/certifications:

Assessment Certification, become American Association of Nurse Assessment Coordination (AANAC) upon hire