MDS/ Restorative Nurse

About the Role

The MDS Coordinator / Restorative Nurse is responsible for the accurate and timely completion of all Medicare/Medicaid case-mix documents to assure appropriate reimbursement for care and services provided within the Facility. This role conducts continual Minimum Data Set (MDS) reviews to achieve optimal allowable Resource Utilization Group (RUG) category and oversees the overall process and tracking of MDS/Prospective Payment System (PPS) documentation and submission.

The incumbent integrates nursing, dietary, social recreation, restorative, rehabilitation, and physician services to ensure appropriate assessment and reimbursement. Additionally, they develop, implement, monitor, and supervise the restorative nursing program for the facility, acting as the liaison between formalized therapy and nursing while promoting a restorative nursing philosophy among facility departments.

Responsibilities

• Assesses and determines the health status and level of care of all new admissions.
• Ensures the accurate and timely completion of all MDS Assessments including PPS Medicare, quarterly, annual, and significant change assessments.
• Communicates level of care for new residents to all disciplines.
• Coordinates interdisciplinary participation in completing the Minimum Data Set (MDS) for each new admission according to regulatory time frames.
• Ensures completeness and thoroughness of documentation as mandated by federal, state, and medical standards.
• Maintains an accurate schedule of all MDS assessments, including proper reference dates throughout the resident’s stay.
• Responsible for data entry to assure accurate electronic submission of MDS assessments.
• Verifies electronic submissions of MDS, performs corrections when necessary, and maintains appropriate records.
• Schedules and conducts resident care conferences in compliance with state and federal regulations.
• Assists disciplines in formulating and revising care plans, ensuring resident’s present/potential problems are identified and prioritized.
• Evaluates resident care plans for comprehensiveness and individuality, reassessing and revising as needed.
• Responsible for all level of care changes within the facility and notifies all departments of changes.
• Generates appropriate forms for level of acuity and changes, transmitting them to the appropriate agency as required by state law.
• Assists in the development, organization, and implementation of nursing care philosophy, objectives, policies, and standards.
• Confers with the Director of Nursing/Assistant Director of Nursing to assess the quality of nursing care and identify areas for improvement.
• Makes daily rounds to evaluate patient care, monitor nursing practices, and assist with educational needs.
• Performs rehabilitation assessments for new admissions and existing patients on a quarterly basis and as needed.
• Performs or oversees functional evaluations on admission, quarterly, and/or as clinically indicated.
• Oversees that all restorative nursing measures are reflected on the care plan.
• Works closely with the therapy department to ensure recommendations are carried through post-discharge.
• Reviews weekly documentation for residents receiving restorative services and ensures proper ADL documentation.
• Oversees incontinent management programs.
• Attends care planning conferences, Interdisciplinary/QAPI meetings, and provides feedback on restorative service needs.
• Coordinates with Human Resources and Director of Nursing to orient new staff on restorative nursing principles and practices.
• Provides ongoing education/evaluation of direct care staff on restorative nursing roles and responsibilities.
• Actively participates in physical restraint reduction and fall management programs.
• Sets up documentation flow sheets for daily restorative nursing measures.
• Performs or supervises the performance of restorative nursing staff.
• Serves as a liaison with all therapists: physical, occupational, and speech.
• Participates in patient care planning and CMI meetings.
• Serves in the role of Medicare Services Coordinator (MDS Coordinator) as needed.
• Puts patients first, ensuring high-quality service in a caring and compassionate atmosphere.

Requirements

• RN or LPN with current unencumbered state license.
• 3–5 years of equivalent clinical experience.
• Current CPR certification.
• Long-term care experience preferred.
• Ability to read, write, speak, and understand the English language.

Physical Demands

• Required to sit, stand, bend, and walk regularly.
• Lift and/or move up to 25 pounds.
• Visual and auditory ability sufficient for written and verbal communication.
• The noise level in the work environment is usually moderate.