Karla Libby, RN

• Acts as a bridge between Healthcare providers, social services and the community facilitating communication and collaboration
• Conducts comprehensive care needs assessments, completing a care management treatment plan specific to patients.
• Assess, plan, implement, monitor, and evaluate options and services to meet complex psychosocial health needs.
• Place external behavioral health and/or substance use community-based referrals to assist patients in accessing quality and cost-effective care.
• Coordination of care with internal and external resources to meet identified patient needs.
• Monitor and evaluate effectiveness of care plan, and modify plan as needed.

MDS Coordinator

• Use of the Resident Assessment Instrument (RAI) to promote the physical and emotional well-being of the sub-acute facility patients and residents
• Coordinate and assist with completion and submission of accurate and timely interdisciplinary MDS assessment, CAA's and care plans according to CMS RAI manual Regulations and in accordance with all applicable laws and regulation
• Review final validation reports and attest that all assessments have been completed and accepted into the CMS QIES system prior to billing and notify business office when assessments are not ready to bill
• Education to direct care staff regarding updates or changes to the SMS RAI Manual or skilled nursing facility regulations
• Maximize PDPM reimbursement through PPS meeting with interdisciplinary team
• Implement, review and revise interdisciplinary comprehensive care plans
• Work closely with internal and external case managers, social worker and director of rehab to coordinate skilled care needs and safe discharge planning in accordance with proper Medicare rules and regulations
• Review Quality Measures to facilitate better patient outcomes and improve 5-star facility ratings.

MMQ Coordinator

• Review all documentation related to the MMQ process to accurately reflect the patients status and maximize Medicaid reimbursement
• Responsible for the timely and accurate completion of all MMQ assessments
• Work closely with the business office for accurate billing
• Education with direct care staff on coding and documentation of patients to capture skilled care needs while maximizing MMQ reimbursement

Case manager

• Lead the Interdisciplinary Team in the coordination of all aspects of patient care including goals of care, clinical needs and discharge planning for complex patients
• Education with family on skilled needs and skilled criteria
• Liaison between patient, physician and external case managers to ensure a comprehensive treatment plan
• Ensure patients meet skilled criteria under CMS guidelines and managed care contracts
• Issue Non-coverage letters for Medicare and Managed care
• Advocate for patients and families as needed to ensure successful transition to community

MDS Coordinator

Case manager