Job Summary
We are seeking a dedicated and detail-oriented MDS Registered Nurse to join our healthcare team. In this vital role, you will be responsible for coordinating and completing the Minimum Data Set (MDS) assessments for residents in long-term care facilities, ensuring compliance with federal and state regulations. Your expertise will support accurate clinical documentation, facilitate quality care planning, and optimize reimbursement processes. You will collaborate closely with interdisciplinary teams to promote exceptional patient care and uphold the highest standards of health information management.
Responsibilities
- Conduct comprehensive MDS assessments in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines, ensuring timely completion for each resident.
- Review and analyze medical records, clinical documentation, and healthcare data to accurately complete MDS items, including CPT coding, ICD-9/ICD-10/ICD coding, DRG (Diagnosis-Related Group), and other relevant classifications.
- Collaborate with nursing staff, physicians, case managers, and other healthcare professionals to gather necessary information for accurate assessments.
- Ensure compliance with all applicable health regulation policies, long-term care regulations, Medicare regulations, HIPAA (Health Insurance Portability and Accountability Act), and NCQA (National Committee for Quality Assurance) standards.
- Support utilization management and review processes by reviewing documentation to optimize patient care plans and reimbursement strategies.
- Maintain proficiency in EMR/EHR systems such as Cerner, Epic, Athenahealth, eClinicalWorks, and other electronic health record systems to document assessments accurately.
- Participate in discharge planning, hospice care coordination, and case management activities to enhance patient outcomes.
- Conduct ongoing education on clinical documentation standards and updates in healthcare regulations to ensure best practices are followed.
Skills
- Extensive knowledge of medical terminology, anatomy, physiology, and clinical documentation standards.
- Proven experience with MDS assessments within long-term care or skilled nursing facilities; ICU or hospital experience is a plus.
- Strong understanding of Medicare/Medicaid regulations and reimbursement methodologies including CPT coding, ICD coding (ICD-9/ICD-10), DRG assignment, and utilization review processes.
- Proficiency with EMR/EHR systems such as Cerner, Epic, Athenahealth or similar platforms; experience with Microsoft Office Suite is preferred.
- Familiarity with health regulation policies including HIPAA, CMS guidelines, state healthcare regulations, and long-term care standards.
- Critical care experience or acute care background enhances ability to interpret complex medical records effectively.
- Excellent communication skills for collaborating across multidisciplinary teams while maintaining compliance with documentation review protocols.
- Ability to prioritize tasks efficiently in a fast-paced environment while maintaining attention to detail.
Join our team if you’re passionate about delivering high-quality patient care through meticulous documentation and regulatory compliance! This paid position offers an opportunity to make a meaningful impact on residents’ lives while advancing your expertise in healthcare management.
Benefits:
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
