Mds Care Coordinator

ESSENTIAL RESPONSIBILITIES

Fully embraces a culture of hospitality and teamwork by living the Oakwood Core Values:

• • Compassion: We care deeply about the people we serve and the people we work with on a daily basis. We work together to help one another.
  • Faith: We have a commitment to remain true to the vision and mission of Oakwood.
  • Inclusion: We include everyone. We welcome opinions and strive to consider different perspectives to create fair, welcoming, and accessible experiences for all.
  • Integrity: We work to be transparent and fair. We act with honor and respect for our residents, their families, and our co-workers.
  • Dedication: We care about the people we serve and work with on a daily basis. We are dedicated to providing superior service to one another and our community.
• Facilitates the admission process, assessment, and resident orientation upon arrival to the facility.
• Oversees the MDS assessment process, sets the assessment schedules and assures that assessments are done in an accurate and timely manner and in compliance with Federal and State regulations.
• Coordinates the care plan as according to regulatory requirements. They must ensure that important resources are made available to patients and that patient care is delivered effectively and to a satisfactory standard.
• Is responsible for coordination with nursing staff for all clinical admission tasks and assessments in electronic medical record.
• Makes daily rounds on units and collaborates with Nursing Staff and/or Social Services; reviews clinical records, and resident care plans.
• Maintains contact with the resident to assess adjustment to setting and response to treatment as needed and reports to Interdisciplinary Team as appropriate.
• Begins the discharge planning process on admission and coordinates the plan of care with the interdisciplinary team.
• Coordinates discharge care conferences within 72 hours of admission with resident, health care representative, and interdisciplinary team.
• Attends all additional resident care conferences.
• Facilitates any required resident and/or family teaching and arranges for any follow up care required after discharge in collaboration with nursing staff and Social Services.
• Attends and/or delegates to nursing staff telehealth visits. Collaborates with Unit Secretary and Social Services in scheduling of telehealth visits as appropriate.
• Collects (in conjunction with Health Information Coordinator) and evaluates outcome data including re-hospitalization rates, analyzes chart of hospitalized patients to identify trends or issues, to ensure outcomes within recommended quality measures.
• Completes a comprehensive chart review of all patients readmitted or transferred to ER and assists with communication of staff education.
• Coordinates patient and responsible party education regarding disease management with the interdisciplinary team to include medication management at the time of discharge.
• Facilitates reintegration into the community with Social Services, patient, responsible party, and post skilled facility partners to include primary physician follow up appointment, and is responsible for the recapitulation of stay.
• Serves as liaison between patient, physicians, and family members in regard to transition of care.
• Participates in in‑services and other ongoing education, as necessary. Participates in staff orientation and development programs.
• Make independent decisions concerning assignments of resident care to LPN's and Nursing Assistants, changes of assignments, daily care of residents, preparing appropriate documentation concerning conditions of residents, and other daily activities.
• Performs other duties as assigned, including responding to an emergency event and/or working as a floor nurse as directed by the Director of Resident Care Services.

ESSENTIAL QUALIFICATIONS:

1. Possesses deep knowledge of both the State of Wisconsin regulations and the Code of Federal regulations, preferred.
2. Demonstrates knowledge of the RAI process and Medicare requirements, preferred.
3. Proven ability to work in a collaborative environment, which fosters effective team work in meeting the mission of One Oakwood.
4. Effectively interacts with other departments of the facility, physicians, pharmacy, local health care providers, residents and their families.
5. Uses independent judgment and make sound decisions.
6. Effectively demonstrates knowledge of current nursing theory and practice, applicable State, Federal, and County laws, rules and regulations pertaining to resident care, residents' rights, and special needs of residents.
7. Provides skilled nursing care and prepare appropriate documentation regarding residents, communicate effectively orally and in writing, and interact effectively with staff, other health care providers, residents and their families.
8. Fulfills physical demands of job, sensory demands (seeing and hearing), and cognitive demands (concentration, conceptualization, memorization.

EXPERIENCE, EDUCATION, AND/OR TRAINING

1. Graduation from an accredited school of nursing
2. Valid licensure as a registered nurse in the State of Wisconsin.
3. Must possess a valid Wisconsin driver's license.
4. Experience in Long Term Care or as a Nurse Care Coordinator Preferred.