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**Our Story**:
Committed to fostering opportunities for current and future generations, the Region of Waterloo is an inclusive, thriving, and sustainable region of connected rural and urban communities with global reach. Our mission is to serve, engage and inspire, by delivering quality services to a diverse population of 630,000+, while creating a healthy, collaborative environment of learning, respect, and innovation.

This is a place where employees are valued and recognized for their talents and contributions to our success. Our employees take pride in making a difference in people's lives through the work that we do. We are looking for people like you to help make it happen.

**Description of Duties**:
Incorporates coding, terminology, and reporting standards into Sunnyside Home documentation practices and policies to ensure compliance with RAI, College of Nurses of Ontario, Ministry of Health and Long Term Care (MOHLTC), and other Provincially-mandated requirements.

Sets deadlines for data input to RAI based on 92-day submission cycle mandated by the Canadian Institute of Health Information (CIHI) data repository for uploading to international RAI database. Creates related data requirement and timeline work plans/schedules for all disciplines within the Home to ensure deadlines are met. Reviews, prepares, and submits RAI data to CIHI. Responds to CIHI on all submission errors.

Oversees and monitors timely completion of minimum data set assessments, resident assessment protocols, and care planning, primarily as it relates to nursing.

Opens and signs-off files for admissions, re-entry, transfers, discharges, and significant changes; tracks occurrences to develop assessment schedules based on these dates. Assigns and communicates residents’ observation periods, resident assessment protocols (RAPs) and care plans to appropriate staff for completion. Completes monthly RAPs and care plans according to assigned residents. Records and signs V-Resident Assessment Protocol (V-RAP) forms.

Monitors and reviews clinical documentation and data entry for accuracy and consistency. Organizes internal reliability audits between coders to ensure accurate and consistent coding and to identify gaps in accuracy. Conducts regular documentation audits and recommends improvements to address issues.

Refers ongoing or complex problems to Administrator.

Supports RAI users by developing standard operating procedures that ensure data accuracy, efficient collection, timely completion, and effective utilization. Assists users to code assessments correctly and reviews to validate coding.

Participates on committees (e.g., RAI Project Team, Accreditation Team, Charting Team, other clinical teams) to provide input and recommendations regarding system developments, Provincial changes, and identified trends and /or issues related to documentation and coding practices.

Retrieves and analyses quality indicators and outcome reports from CIHI.

Communicates quality indicators obtained from Point Click Care and/or CIHI, areas for improvement, progress, and achievements with RAI users and management team.

Generates RAI reports and reviews with leadership team, frontline registered staff and Personal Support Workers (PSWs) for use in clinical and operational decision-making. Recommends changes in nursing practices, policies, and procedures to Administrator, Resident Care, based on information gleaned from reports.

Recommends improvements to optimize the Home’s use of RAI as a funding mechanism from the Province.

Coordinates, develops, and conducts individual and group training regarding clinical documentation and related software for existing and new RAI users. As RAI expert, provides ongoing leadership and support to RAI users as required/requested.

Problem solves complicated RAI-related issues (e.g., technical issues, complicated data submissions) using manual, Provincial help-desk, and vendor support.

Maintains and instructs other Home staff in use of Focus Charting system, including documentation and ensuring accuracy and consistency in practices.

Maintains competency on RAI process by participating in educational sessions.

Performs Registered Nurse duties as required.

Performs other related duties as assigned.

**Knowledge, Skills & Abilities Required**:
Thorough knowledge of current RAI system, normally acquired through RAI training and certification as well as experience working with and leading others in the use of RAI.

Thorough practical knowledge of nursing methods and procedures acquired as a Registered Nurse with current registration with the College of Nurses of Ontario, plus current gerontogical nursing experience including psychogeriatrics and clients with dementias.

Computer skills using a clinical software system (e.g., Point Click Care), as well as Microsoft Office, Outlook, and the Internet.

Thorough knowledge of the College of Nurses of Ontario documentation standards, and MOHLTC and RAI documentation r