Job Overview
We are seeking a dedicated and detail-oriented Minimum Data Set (MDS) Nurse to join our healthcare team. In this vital role, you will be responsible for conducting comprehensive assessments of residents in long-term care settings, ensuring compliance with federal and state regulations, and supporting quality patient care through accurate data collection and documentation. Your expertise will help optimize care plans, facilitate reimbursement processes, and uphold the highest standards of clinical documentation improvement. If you thrive in a fast-paced environment and are passionate about improving patient outcomes through precise data management, this opportunity is perfect for you!
Responsibilities
- Conduct thorough Minimum Data Set assessments for residents to evaluate their clinical status, functional abilities, and care needs in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines.
- Review and analyze medical records, clinical documentation, and coding information including ICD-10/ICD-9 codes, CPT codes, DRGs, and other medical terminology to ensure accuracy and completeness.
- Collaborate with interdisciplinary teams—including nursing staff, physicians, case managers, and therapy providers—to develop individualized care plans aligned with regulatory standards such as NCQA and long-term care regulations.
- Maintain up-to-date knowledge of health regulation policies, HIPAA compliance, Medicare requirements, and state healthcare regulations to ensure all documentation meets legal standards.
- Utilize EMR/EHR systems such as Cerner, Athenahealth, eClinicalWorks, or similar platforms to document assessments accurately and efficiently while managing electronic health records (EHR).
- Support utilization review and management activities by reviewing clinical documentation for appropriateness of services and ensuring proper coding for reimbursement purposes.
- Participate in discharge planning processes including hospice care coordination, outpatient services, or transitions to home care settings to optimize patient outcomes.
Qualifications
- LVN OR RN license with current state licensure.
- Proven experience in long-term care facilities such as nursing homes or skilled nursing facilities.
- Strong knowledge of MDS processes, clinical documentation standards, and healthcare regulations including CMS guidelines.
- Familiarity with medical coding systems such as ICD-10/ICD-9, CPT coding, DRGs, and utilization management principles.
- Experience working with EMR/EHR systems like Cerner, Athenahealth or eClinicalWorks; proficiency in electronic health records management is highly desirable.
- Critical care experience or ICU background is preferred; inpatient experience at Level I or Level II trauma centers adds value.
- Knowledge of physiology, anatomy, medical terminology, discharge planning, case management strategies, and health information management practices.
- Excellent communication skills to collaborate effectively across multidisciplinary teams while maintaining HIPAA compliance.
Join us to make a meaningful impact on patient care through expert data management! We are committed to fostering a supportive environment where your skills can flourish while ensuring the highest standards of clinical documentation improvement and healthcare excellence.
Pay: $40.00 - $45.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
