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(Westerville Post Acute) Westerville SNF Healthcare, LLC

MDS

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.

$71,953 / year median in Ohio

-4% projected decline

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Job Description

Essential Duties and Responsibilities Coordinate the MDS assessment process from admission through discharge. Complete and/or coordinate accurate and timely MDS assessments, including required scheduled, significant change, and discharge assessments. Review clinical documentation to ensure the MDS accurately reflects the resident's current condition and services provided. Coordinate the interdisciplinary assessment process and obtain required documentation from nursing, therapy, dietary, social services, activities, and other departments. Maintain accurate MDS schedules and ensure assessments are completed within required regulatory timeframes. Participate in care plan meetings and ensure MDS findings are incorporated into individualized resident care plans. Monitor documentation for accuracy, completeness, and consistency with MDS coding. Communicate with physicians, nurse practitioners, therapists, nursing staff, and other healthcare professionals regarding resident status and documentation needs. Identify documentation discrepancies and work with appropriate departments to resolve them. Support accurate coding and reimbursement by ensuring that qualifying services and resident conditions are appropriately documented. Monitor Medicare and managed-care requirements related to MDS, reimbursement, and skilled services. Assist with Quality Measures and other regulatory reports as applicable. Maintain current knowledge of CMS regulations, RAI requirements, MDS coding guidelines, and applicable state requirements. Assist with preparation for state surveys, audits, and other regulatory reviews. Educate staff regarding MDS requirements, documentation standards, and changes in regulations. Maintain confidentiality of resident information in accordance with HIPAA and facility policies. Perform other duties as assigned by the Director of Nursing or Administrator. Qualifications Current Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN) license as required by state regulations. Previous long-term care or skilled nursing facility experience preferred. Previous MDS/RAI experience strongly preferred. Knowledge of CMS regulations, MDS 3.0, RAI requirements, and long-term care documentation practices. Strong clinical assessment, organizational, communication, and problem-solving skills. Ability to meet strict regulatory deadlines and manage multiple priorities. Proficiency with electronic medical records and MDS software. Preferred Experience 1-3 years of long-term care/SNF nursing experience. MDS Coordinator or MDS Nurse experience. Experience with Medicare reimbursement, PDPM, care planning, and quality measures. Experience participating in state surveys and regulatory audits. Physical and Work Requirements Ability to work effectively in a skilled nursing facility environment. Ability to communicate with residents, families, staff, and healthcare providers. Ability to review and maintain extensive clinical documentation. Ability to meet deadlines and work independently while collaborating with an interdisciplinary team. Key Performance Expectations The MDS Coordinator is expected to maintain accurate and timely assessments, support regulatory compliance, promote accurate reimbursement, facilitate effective interdisciplinary communication, and ensure that resident care plans accurately reflect assessed needs. We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.