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Atlas Rehab and Healthcare at Maywood

MDS Coordinator

Career Insights for Clinical Documentation Specialist

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What they do

A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.

$73,423 / year median in New Jersey

+5% projected growth

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Job Description

Major Duties and Responsibilities Coordination of the facility's Resident Assessment Instrument (RAI) process in accordance with state and federal regulations. Accurate completion of all MDS assessments and any supporting assessments or clinical documentation. Implementation and ongoing evaluation of each resident's comprehensive plan of care. Scheduling and leading interdisciplinary care plan team meetings. Auditing medical records for the presence of supporting documentation for all items coded on the MDS. Provide education to department heads, physicians, and other staff as needed. Collaborating with health plans, physicians and the interdisciplinary team for assuring insurance approvals and/or that residents meet eligibility and coverage criteria. Interpreting rules, regulations and coverage guidelines and acting as primary resource for problem solving in regards to the SNF prospective payment system and quality reporting program