With a proven track record at Springtree Rehab and Health Care Center, I leveraged strong organizational skills and bilingual capabilities to enhance patient outcomes through effective MDS coordination and care plan development. My collaborative approach and excellent assessment abilities ensured compliance and optimized care, significantly improving resident care quality.
Overview
2025
2025
years of professional experience
1
1
Certification
Work History
MDS Coordinator
Springtree Rehab And Health Care Center
03.2008 - Current
Set schedules for staff to start and complete MDS assessments and care plan meetings.
Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
Ensured accurate reimbursement claims by diligently tracking changes in patient conditions and updating MDS accordingly.
Enhanced patient care by developing and implementing comprehensive MDS plans tailored to individual needs.
Collaborated with interdisciplinary teams to ensure optimal patient outcomes and consistent quality of care.
Verified prompt and accurate completion of MDS activities for billing.
Assessed electronic medical record for required documentation to support MDS coding.
Completed minimum data set assessments with strong collaboration across business, provider and clinical disciplines.
Led weekly utilization review to go over recent clinical activities.
Trained staff in correct techniques for completing and signing MDS assessments.
Participated in quality assurance reviews to verify accuracy and reliability of data.
Enhanced patient care quality by implementing comprehensive MDS assessments and care plans.
Collaborated with nursing staff to provide accurate and timely clinical assessments for each resident, leading to improved overall care.
Collaborated closely with therapy departments to accurately capture rehabilitation needs within MDS documentation, supporting appropriate resource allocation for residents'' needs.
Provided ongoing education for nursing staff regarding MDS best practices, contributing to a knowledgeable and skilled workforce.
Implemented interdisciplinary meetings focused on individualized care plan development, resulting in more targeted interventions and improved resident outcomes.
Developed a comprehensive system for tracking MDS completion deadlines, ensuring timely submissions and minimizing the risk of financial penalties.
Developed strong relationships with interdisciplinary team members to facilitate efficient collaboration on resident care planning.
Provided guidance to nursing staff on accurate completion of Section GG assessments, enhancing overall documentation quality and supporting appropriate Medicare/Medicaid reimbursement rates.
Complied with federal and state regulations for completion and coordination of RAI process.
Coordinated multidisciplinary care team meetings to enhance communication and ensure consistency in patient care delivery.
Improved patient outcomes with comprehensive assessments, identifying changes in condition and adjusting care plans accordingly.
Assistant Director of Nursing
Springtree Rehab And Health Care Center
Restorative Nurse
Springtree Rehab And Health Care Center
Manage Care Case Manager
Springtree Rehab And Health Care Center
10.2004 - 03.2008
Exhibited strong communication skills to educate patients and families on health management and care options.
Developed comprehensive care plans tailored to individual patient needs, promoting optimal health outcomes.
Applied knowledge of community resources to connect patients with relevant services, ensuring comprehensive care.
Educated patients and families on disease process, treatment options, and available community resources to empower informed decisionmaking.
Facilitated timely discharges by coordinating appropriate post-acute care services for patients.
Streamlined case management processes by maintaining accurate documentation and utilizing up-to-date technology tools.
Increased efficiency in care coordination by establishing strong relationships with external providers such as home health agencies, rehabilitation centers, and hospice organizations.
Advocated for patient needs during interdisciplinary meetings to ensure optimal care delivery tailored to individual preferences.
Mitigated patient discharge delays by coordinating tests, therapy and other treatments.
Served as a reliable point of contact for healthcare providers seeking guidance on complex cases or care coordination best practices.
Communicated with healthcare providers to facilitate continuity of care.
Assessed clients and developed plans to meet needs.
Maintained network of community resources to provide most comprehensive support services possible to clients.
Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for patients.
Arranged transportation and documented details of discharge transition plans.
Assisted patients in accessing housing, financial assistance and other community resources.
Case Manager
Sunrise Health and Rehab
11.2002 - 10.2004
Education
RN Diploma - Nursing
St. Elizabeth's Nursing School
Boston
Skills
Organized
Able to work independently
Able to collaborate care with resident and family
Bilingual - Fluent in English and Spanish
Good communication skills with resident's and family
Excellent assessment skills and ability to evaluate the quality of care and or need for additional therapy
Certification
First Aid Certification - Effective 6/04/2024
CPR/AED Certification - Effective 6/04/2024
Florida State RN license - Effective 7/30/2024
PASRR SCREENING AND NHSN Logging
PASRR screening- Responsible for completing and submitting a comprehensive evaluation (LEVEL 1 or LEVEL 2) on individuals being admitted to a Medicaid-certified nursing facility regardless of their payment source.
NHSN- LTCF are required to electronically report information about resident and staff COVID-19, Influenza and RSV vaccination status, any confirmed cases and/or hospitalized cases to CDC.
Languages
Spanish
Native or Bilingual
English
Native or Bilingual
Timeline
MDS Coordinator
Springtree Rehab And Health Care Center
03.2008 - Current
Manage Care Case Manager
Springtree Rehab And Health Care Center
10.2004 - 03.2008
Case Manager
Sunrise Health and Rehab
11.2002 - 10.2004
First Aid Certification - Effective 6/04/2024
CPR/AED Certification - Effective 6/04/2024
Florida State RN license - Effective 7/30/2024
Assistant Director of Nursing
Springtree Rehab And Health Care Center
Restorative Nurse
Springtree Rehab And Health Care Center
RN Diploma - Nursing
St. Elizabeth's Nursing School
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