MEDICARE NURSE

JOB SUMMARY:

The Medicare Nurse Case Manager (MNCM) will coordinate the nursing aspect of the Medicare program, including screening for skilled care, pre-admissions, admissions, nursing documentation and evaluations for continued stay, to ensure an effective Medicare program. Monitors the assignment of patients to Resource Utilization Groups (RUGs), utilization of resources used in treatment and the assignment of RUGs payment periods associated with the Minimum Data Set (MDS) schedules. Works with the Billing Department to coordinate patient services utilization, RUGs payment categories, and UB 04 coding. Develops and maintains on-going MDS schedules for each patient. Communicates with physicians / nurses / CNAs / coworkers / interdisciplinary team members and families, as appropriate, regarding patient’s clinical condition. Responds timely and accurately to changes in patient’s condition or response to treatment by initiating assessment action plan. Follows a flexible work schedule to cover weekend admissions. Performs general nursing duties as required. The Medicare Nurse Care Manager is responsible to the Director of Nursing Services.

EDUCATION:

Must be a Licensed Nurse. Must be a graduate of an accredited school of nursing currently registered with the state agency for nursing licensure and certification and hold a valid license in the state he/she is employed.

QUALIFCATIONS:

1. Experience in long term care preferred. Experience in Medicare preferred but not required.
2. Has ability to work well with general public.
3. Demonstrates leadership and management ability.
4. Is capable of implementing changes as mandated by Federal, State and management suggestions.
5. Is of good emotional, mental and physical health, having sound judgment and high professional standards.
6. Maintains a neat, well-groomed and professional appearance at all times.
7. Must be willing to be in the facility working with the staff of each shift if need arises.
8. Must be willing to be in and/or available to the facility weekends as well as weekdays as needs arise.
9. Must demonstrate the ability to function as a cooperative team member with all disciplines in the facility.
10. Is willing and capable of providing emergency care as needed for any resident in the facility.
11. Experience in case management, rehabilitation nursing, long term care, Medicare nursing documentation and Minimum Data Set (MDS) coding preferred.
12. Demonstrates an attitude for providing a high degree of patient satisfaction and services.
13. Demonstrates experience working in a positive collaborative relationship with the members of the community.
14. Must have a pre-employment and an annual Tuberculosis test and/or screening.

RESPONSIBILTIES:

1. Makes rounds of Medicare patients at least daily.
2. Works closely with admissions to assess all inquiries for possible Medicare admissions.
3. Visits or arranges for the visit of an appropriate clinical representative to pre-screen potential patients for admission and readmission to the facility.
4. Screens all new admits and readmissions for skilled care in accordance with facility policies and procedures.
5. Interacts with discharge planners and staff from referring facilities, agencies and hospitals to pre-screen potential patients for admission and readmission to the facility.
6. Responsible for skilled nursing documentation on Medicare patients, either through actual documentation or audits.
7. Responsible for all required nursing documentation for Medicare nursing to include any other record keeping required by the program for nursing.
8. Assesses Medicare residents for continued stay on continuous basis and tracks remaining days in unit.
9. Manage and collaborates with the MDS Team on pre-admission screening, assignment of observation and look-back periods; informs the interdisciplinary team regarding changes in look-back periods for the MDS completion including the implementation of a “significant change” MDS/plan of care processes.
10. Assigns the admission RUG category for payment for the initial five day Medicare MDS in collaboration with the MDS Team.
11. Establishes individual MDS schedules and coordinates assessment activities across clinical disciplines for each patient following regulatory requirements.
12. Ensures the MDS’s are encoded, edited, locked and electronically transmitted within the required time frames.
13. Initiates and coordinates patient discharge plan upon admission to the facility in collaboration with the social services, admissions, clinical team, patient and facility.
14. Performs a nursing physical and psychosocial MDS assessment on all patients and reassessments as per the MDS scheduled requirements unless these are assigned to other clinical disciplines for completion.
15. Determines the RUG categories of Medicare payments for patients based upon the MDS assessments and in collaboration with the MDS team.
16. Reviews and sends the MDS scores and RUGs categories to the billing office within the required time frames.
17. Identifies cost variances and recommends cost recommends cost controls related to resource utilization.
18. Demonstrates ability to directly perform treatments and provide services to the level of licensure.
19. Knowledge of medication and their correct administration based on age of the patient and their clinical condition.
20. Consults other departments as appropriate to provide for an interdisciplinary approach to the patient’s care.
21. Demonstrates an ability to assist physicians with procedures and performs services requiring technical and manual skills.
22. Demonstrates an ability to be flexible, organized, and function under stressful situations.
23. Treats patients and their families with respect and dignity; ensures patient confidentiality and privacy.
24. Maintains a good working relationship both with all departments and with contacts from referring facilities and agencies.
25. Oversees patient care cost, acquisition and/or rental of medical equipment and supplies used with patients as ordered by the physician and noted in the plan of care.
26. Coordinates and supervises Medicare patient care activities as necessary to optimize resource utilization.
27. Attends meetings as required to include Medicare staff meetings, therapy meetings, and care plan meetings for skilled residents.
28. Coordinates care planning with Assessment Nursing for skilled residents.
29. Prepares requests for issuance of denial letters on admission and readmission.
30. Assists with discharging skilled residents.
31. Sees that supplies are available in proper quantities, that equipment is available in good condition and that personnel using such supplies and equipment know where such are to be found and know the proper care and use.
32. Assists with in-servicing to individualized needs.
33. Gives guidance to personnel as needed, evaluates performance, discusses progress and needs for improvement and prepares evaluations of performance as directed.
34. Assists the DON in other duties as directed.

PROFESSIONAL REQUIREMENTS:

1. Adheres to dress code, appearance is neat and clean.
2. Completes annual educational requirements per policy.
3. Maintains regulatory requirements.
4. Occasional travel/overnights required for training and professional meetings.
5. Reports to work on time and as scheduled. Completes work within designated time.
6. Wears identification while on duty.
7. Completes in-services and returns to work in timely manner.
8. Attends specified staff meetings, reads and returns all information required by immediate supervisor.

REGULATORY REQUIREMENTS:

1. Current State Nurse Licensure

LANGUAGE SKILLS:

1. Ability to read and communicate effectively in English.
2. Additional languages preferred.

SKILLS:

1. Current nursing assessment knowledge
2. Ability to develop plans of care
3. Ability to document patient care outcomes
4. Basic computer knowledge
5. Ability to organize and implement MDS and plan of care schedules

PHYSICAL REQUIREMENTS:

1. Ability to drive and possess a valid/current driver’s license.

PHYSICAL DEMANDS:

Use the percentages range as follows:

• 0% Never
• 1 - 33% Occasional
• 34 - 66% Frequent
• 67 - 100% Continuous

Requires full range of body motion including:

1. Standing/Walking: Continuously .

• Worker will be standing or walking during entire tour of duty.

2. Bending/Stooping: Frequently .

• Worker will be bending and stooping as he/she supervises, assists staff, assesses residents/care, etc.

3. Lifting/Handling: Frequently .

• Worker will be lifting and handling residents as supervises, assists, assesses residents/care being provided. Range of Weight: 1-50 pounds.

4. Carrying: Frequently .

• Worker will be carrying equipment and supplies as supervises, assists, assesses residents/care being provided. Range of Weight: 1-50 pounds.

5. Push/Pull: Frequently .

• Worker will be pushing and pulling equipment and supplies as supervises, assists, assesses residents/care being provided. Range of Weight: 1-50 pounds.

6. Balancing: Frequently .

• Worker will be balancing as supervises, assists, assesses residents/care being provided, etc.

7. Twisting/Turning: Frequently .

• Worker will be twisting and turning as supervises, assists, assesses residents/ care being provided, etc.

8. Crouching/Stooping: Frequently .

• Worker will be crouching or stooping as supervises, assists, assesses residents/care being provided, etc.

9. Kneeling: Frequently .

• Worker will be kneeling as supervises, assists, assesses, residents/care being provided, etc.

10. Reaching:

• Worker will be reaching as supervises, assists, assesses residents/care being provided, etc.

1. Greater than shoulder height: Frequently .
2. Equal to shoulder height: Frequently .
3. Less than shoulder height: Frequently .

11. Handling/Manual Dexterity: Continuously .

• Both fine and gross motor skills are needed for all tasks throughout the working day.

12. Speaking/Hearing/ Seeing: Continuously .

• Must be able to communicate with co-workers, residents, visitors, families, and physicians. J

JOB LOCATION:

Must work throughout all areas of the facility. Works primarily on Medicare unit but as job demands. May require working irregular hours and may be exposed to communicable diseases and/or body fluids, medical preparations, toxic substances and occasionally ionizing radiation.