Job Description

Job Description

Job Description

Position Description: Position Title:
MDS / Clinical Review LPNDepartment:
Skilled Nursing and Rehab Facility / Long Term Care
FLSA:
Hourly / Non-Exempt;
Supervisor:
MDS CoordinatorSupervises:
N/AJob Location:
In- Person/OnsiteWelcome to Legacy Pointe at UCF!
Legacy Pointe at UCF is a premier continuing care retirement community in the heart of Oviedo, Florida. Our state-of-the-art community is uniquely affiliated with the University of Central Florida, offering residents access to lifelong learning, innovative programs, and an exceptional quality of life.
At Legacy Pointe, we embrace the Pinnacles of Hospitality, Service, and Accountability. These values guide our commitment to creating warm welcomes, delivering outstanding care, and taking pride in our responsibilities.
We are currently seeking passionate and skilled professionals to join our team and contribute to the vibrant culture that makes Legacy Pointe so special. If you are ready to make a difference and be part of an innovative and caring community, we would love to meet you!
To learn more about Legacy Pointe, visit our website: where you can explore Lifecare, Living Options, and our commitment to Lifelong Learning.
Position Summary:
The Clinical Review Nurse / MDS Nurse (LPN) is responsible for reviewing and responding to all hospital referrals, ensuring timely and accurate admission processes, and providing ongoing communication and education to nursing staff regarding new admissions. This role also assists with the completion of MDS assessments in compliance with federal and state regulations, ensuring accurate documentation and contributing to the facilitys reimbursement and quality initiatives. The position requires a strong clinical background, attention to detail, and the ability to work collaboratively with multiple departments to ensure smooth transitions of care and regulatory compliance. Duties and responsibilities will be completed while demonstrating behaviors that align with our communitys service excellence philosophy and core values.
Essential Duties and Responsibilities:
The following duties are normal for this position. This list is not to be construed as exclusive or all inclusive. Other duties may be required and assigned.
Provides clinical review and response to all hospital referrals within 20 minutes of receipt from the Admissions Coordinator or Hospital Liaison.
Prioritizes all clinical reviews for timely and accurate communication.
Completes admission packets with residents and/or family members as a backup to the Admissions Coordinator.
Provides direction and education to nursing floor staff for patient care on all new admissions.
Communicates with nurse leadership and floor staff regarding patient needs for new admissions.
Reviews MAR/TAR and coordinates with pharmacy prior to admission to ensure necessary medications are available.
Reviews pain management plans to ensure appropriateness and availability of medications.
Communicates with attending physicians and/or nurse practitioners regarding any specified needs for new admissions.
Completes and reviews admission checklists pre- and post-admission, providing updates to the Director of Nursing.
Ensures that staff receive education on new admissions and the admissions process.
Assists with admissions as directed by the Healthcare Administrator or Director of Nursing.
Completes pre-admission assessment forms and provides admission analysis to the QAPI committee.
Maintains adherence to the professional code of ethics and facility policies.
Completes and submits MDS assessments in compliance with federal and state requirements, including OBRA and PPS assessments.
Accurately collects and inputs assessment data from resident records, direct observation, and interdisciplinary team collaboration.
Coordinates with nursing, therapy, and social services to ensure timely and accurate completion of all sections of the MDS.
Reviews medical records to validate clinical documentation supporting MDS coding.
Tracks MDS schedules and ensures all assessments are completed within required time frames.
Assists in the development and updating of Care Area Assessments (CAAs) and individualized care plans based on MDS findings.
Participates in interdisciplinary care plan meetings to review resident progress and care needs.
Monitors and audits documentation to ensure accuracy and regulatory compliance.
Provides education to staff on documentation requirements impacting MDS coding and reimbursement.
Assists in monitoring Quality Measures (QMs) and other MDS-driven facility reports to support quality improvement efforts.Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Educational Requirements and Experience:
Current and active LPN license in the State of Florida.
Minimum of 2 years of experience in long-term care, skilled nursing, or a related healthcare setting.
Prior experience with MDS assessments.
Knowledge of federal and state regulations related to MDS, PPS, and OBRA requirements.
Strong clinical assessment, critical thinking, and communication skills.
Proficiency in EMR systems and Microsoft Office Suite.
Ability to manage multiple priorities and meet strict deadlines.Knowledge, Skills, and Abilities:
Language Ability:
Ability to communicate effectively in writing and verbally, speaking the primary language of the residents.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
Mathematical Skills:
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent, and to draw and interpret graphs.
Cognitive Demands:
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Computer Skills:
Ability to use Microsoft Windows and Point Click Care (PCC) preferred. Ability to use software to design calendars and signs. Ability to use the Internet.
Competencies:
Must demonstrate an interest in working with a senior cognitive impaired population.
Provides leadership by exhibiting confidence in self and others; Inspires and motivates others to perform well.
Interacts with guests, residents and staff in a courteous and friendly manner.
Responds promptly to resident and visitor needs and assistance.
Supports organization's goals and values.
Balances team and individual responsibilities. Manages people effectively by taking responsibility for subordinates' activities; Makes self-available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Improves processes, products and services.
Provides leadership by exhibiting confidence in self and others; Inspires and motivates others to perform well.
Environmental Adaptability:
Works primarily indoors in a climate-controlled setting

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