Position Title: MDS/Clinical Records Coordinator
Reports To: Director of Nursing
Effective Date: November 30, 2012
Position Description: Conduct and coordinate the development and completion of the resident assessment process in accordance with the requirements of the Federal and State regulations as well as Company policy and procedure. Performs administrative duties, record keeping functions, and medical records functions in accordance with facilities policies and procedures. Monitors records for compliance and apprises management; provides critical information such as ICD-9 codes to the business office. Acts as a liaison to the Administrator, DON, and others. Maintains adequate filing system.
Minimum Qualifications: Graduate of an accredited school of nursing with an active license, three (3) years healthcare related experience and/or training, or equivalent combination of education and experience. Must have proficient computer skills with working knowledge of programs such a Word, Excel, Outlook, and preferably MDS software, and experience in medical records management. Must be at least 21 years of age, have a valid Class C Georgia Driver’s License, proof of vehicle insurance, and meet company policy regarding MVR requirements. Must meet state requirements regarding a Georgia, National, and FBI criminal history record check which requires fingerprinting. Must undergo and pass a drug screening, and screening for Tuberculosis and Hepatitis B. Must have current CPR/First Aid certification in accordance with state regulations.
- Analytical Skills
- Business Ethics and Compliance
- Continuous Learning
- Managing Customer Focus
- Managing People
- Planning and Organizing
- Problem Solving
- Safety Management
- Use of Technology
Essential Duties and Responsibilities:
- Oversee and coordinate the development and completion of the resident assessment (MDS) in accordance with current Federal and State rules, regulations, and guidelines that govern the resident assessment, including the implementation of CAAs and Triggers.
- Assemble information from the Initial Nursing Assessment, resident interview, and clinical record review to complete the nursing portion of the MDS.
- Notify all members of the interdisciplinary team in advance of the MDS due date for all new admissions, annual reviews, and significant changes in resident condition. Monitor and follow-up with team members as needed to verify that all assigned sections of the MDS are completed, dated, and signed within designated time frames and that triggered CAAs are completed.
- Review each MDS for accuracy, consistency, completeness, and signatures prior to submitting to the designated RN for final review and signature.
- Verify the face validity of all MDSs before electronic submission.
- Participate in and oversee the timely electronic submission of all MDS.
- Review the validation report and verify that appropriate action is taken.
- Review the Care Area Protocols correlated with nursing issues and answer the questions as identified in the computer documentation system. Once all the questions have been answered complete narrative summaries of the information, indicating the decision whether or not to include the identified problem on the Plan of Care.Consult the CAA summary sheet and verify that all triggered CAAs and corresponding narrative summaries have been completed, dated, and signed by the appropriate disciplines.
- For triggered CAAs included in the Care Plan, verify that any additional supportive documentation related to CAA issues is completed. If a triggered CAA is not included in the Care Plan, verify that documentation in the CAA summary clearly indicates reasons for not proceeding.
- Identify and document nursing problems, goals, and approaches, and coordinate the development of an individual Plan of Care for each resident in cooperation with the interdisciplinary team in accordance with state and federal guidelines.
- Correlate the information to update resident care plans quarterly and after each significant change. Verify that all updates are completed. Generate final copy, and verify that signatures from interdisciplinary team and contributing resident or family members are obtained. Monitor and follow-up with team members as needed to verify that all assigned sections of the MDS are completed, dated, and signed within designated time frames. Make a copy of each resident’s care plan accessible.
- Keep Administrator and DON informed of all resident appointments, etc., and answers telephones in a courteous manner.
- Develop cumulative diagnosis records, assign ICD-9 codes, and list of admission diagnoses for face sheet. Maintains basic chart set up based on Medicare and Skilled Nursing rules and regulations. Update ICD-9 codes as indicated from Medicare meetings and MD progress notes.
- Thin and audit resident records in accordance with thinning schedules as needed.
Reports deficiencies to responsible disciplines for correction and report uncorrected deficiencies to Administrator and DON.
- Maintain filing system for active, overflow, and discharged resident.
- Secure physician’s signature for certs and recerts, DNR consents, and monthly physician’s order sheets in a timely manner. Verify accuracy of daily censes.
- Compile data for survey report as requested by Administrator.
- Complete all tasks as assigned in a timely manner.
- Disseminate any new or updated materials involving the RAI process.
- Communicate with the Senior Accountant, Administrator, and DON on a regular basis regarding the case mix scores and how they impact reimbursement.
- Coordinate the interdisciplinary assessment process for all residents of the facility. Verify that the RAI is individualized, complete, accurate, and timely for each resident.
- Participate in Interdisciplinary Care Plan meetings. Educate peers on MDS, CAA, ICD-9 codes, and Care Plans.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.
Physical and Sensory Requirements:
- Ability to read, write and speak English.
- Ability to apply common sense understanding to carry out detailed written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- While performing the duties of this job, the employee is regularly required to use hands; use fingers; handle or feel; reach with hands and arms; talk; and hear. The employee frequently is required to sit, stand, and walk. Employee is occasionally required to climb or balance; stoop, kneel, crouch, bend, or crawl. Employee is required to lift up to 25 pounds and/or move up to 75 pounds (with assistance). Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Employee may be required to transport (drive) and assist Villagers in and out of vehicles. Employee is required to perform CPR/First Aid.