| Works in collaboration with Interdisciplinary Team to assess the needs of the resident. | |
| Assists with the coordination and management of the Care Management meeting, to include review of the residents care and setting of the Assessment Reference Date. | |
| Complies with federal and state regulations regarding completion and coordination of the RAI process. | |
| Monitors MDS and the care plan documentation for all residents. Ensures documentation is present in the medical record to support MDS coding. | |
| Supports the tracking system of the MDS schedules (timeframes and due dates). | |
| Maintains the frequency and accurate data entry of residents' information into appropriate computerized MDS programs. | |
| Facilitates and attends the Interdisplinary team meeting and other meetings in order to gather information, communicate changes, maintain and update records. | |
| Demonstrates comprehensive knowledge of epidemiology and infection control process in the healthcare setting. |
| Demonstrates understanding of standard and isolation precautions as set forth by the CDC. |
| Attends continuing education programs and maintains current knowledge of all aspects of infection control. |
| Demonstrates knowledge of microbiology, and modes of transmission of disease entities. |
| Demonstrates ability to teach principles and practical application of infection control to all levels of healthcare personnel. |
| Demonstrates ability to develop infection control policies and procedures. |
| Confers with staff nurses on all patient care units on a regular basis to determine occurrence of healthcare associated infections (HAIs). |
| Confers with medical and nursing staff to determine appropriate implementation of isolation precautions. |
| Investigates infections, especially those occurring above established thresholds, and/or in clusters. |
| Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. |
| Works collaboratively with the Employee Health staff and assists with initiating work restrictions related to illness from a communicable disease or infection. . |
| Communicates appropriate reports to the Performance Improvement Committee. |
| Assists with in-service education related to infection prevention and control for all departments. |
| Assists in the development, implementation and improvement of infection control practices. |
| Serves as coordinator for the CCM program. |
| Assists healthcare providers in developing annual comprehensive chronic condition care plans. |
| Orients and educates patients and their families by meeting them; explaining the role of the care coordinator; participate in care planning, and document continuing care requirements. |
| Serves as patient advocate to ensure continuity of care by following patients receiving CCM services across various care settings: Inpatient, Outpatient, Emergency, Home Health, etc. |
| Provides clinical education and support to patient and family around medical processes, procedures, treatments, medications, and management of health and wellness. |
| Perform chart reviews, patient assessments, interview staff/physician, and patient/family, to make thorough and appropriate community referrals. |
| Generate and cultivate referrals based on patient needs and choice. |
| Works collaboratively with all providers and clinical/office staff in pursuit of patient satisfaction and quality care. |
| Maintains patient charts in EHR systems per documentation policies. |
| Facilitates patient access to community resources as appropriate. |
| Manages patient registries. |
| Perform other job related duties and assigned tasks as requested; which may include: cross training and/or other job functions as temporary work loads and volumes require. |
| Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations. |
| Demonstrate the ability to deal with a variety of people, deal with stressful situations, and handle conflict. |
