Overview We are seeking a dedicated and detail-oriented Registered Nurse (RN) or Licensed Practical Nurse (LPN) to serve as an MDS (Minimum Data Set) Coordinator. In this vital role, you will lead the comprehensive assessment and documentation process for residents, ensuring compliance with federal and state regulations, including Medicare and Medicaid standards. Your expertise will support clinical decision-making, optimize patient care, and enhance facility quality measures. This position offers an energetic environment where your nursing skills and clinical documentation proficiency will make a meaningful impact on resident outcomes and facility performance. Duties Coordinate and complete the MDS assessments accurately and timely, ensuring adherence to CMS (Centers for Medicare & Medicaid Services) guidelines and NCQA (National Committee for Quality Assurance) standards. Review medical records, clinical documentation, and care plans to verify completeness and accuracy of data for each resident's assessment. Collaborate with interdisciplinary teams—including nursing staff, physicians, therapy providers, and case managers—to gather pertinent clinical information. Conduct thorough documentation review to identify areas for improvement in coding accuracy, including

ICD-10/ICD-9

coding, CPT coding, DRG (Diagnosis-Related Group) assignments, and utilization review processes. Maintain proficiency in EMR (Electronic Medical Records) systems such as Epic, Cerner, Athenahealth, eClinicalWorks, or similar platforms to ensure seamless data entry and reporting. Support compliance with HIPAA regulations by safeguarding patient information during all documentation activities. Assist with discharge planning, hospice care coordination, and post-acute care documentation to optimize patient transitions across settings such as inpatient facilities or outpatient clinics. Qualifications Valid RN or LPN license with current state licensure. Proven experience in nursing home settings or long-term care facilities; experience with Level I Trauma Centers or Level II trauma centers is a plus. Strong knowledge of MDS processes, Medicare regulations, ICD-10/ICD-9 coding standards, CPT coding, DRG assignment, and utilization management principles. Familiarity with EMR/EHR systems like Epic, Cerner, Athenahealth or similar platforms; experience with clinical documentation improvement initiatives is preferred. Critical care experience—including ICU or PICU—hospital experience or outpatient clinic background is highly desirable. Excellent understanding of medical terminology, anatomy, physiology, and healthcare compliance standards such as HIPAA. Ability to analyze complex medical records efficiently while maintaining attention to detail; strong organizational skills are essential. Knowledge of managed care processes and health information management practices related to discharge planning and case management. Join our team to play a pivotal role in elevating resident care through meticulous documentation and clinical excellence! We're committed to supporting your professional growth while fostering a lively work environment where your expertise makes a difference every day.

Pay:

From $45.00 per hour

Benefits:

401(k) Dental insurance Health insurance Paid time off Vision insurance

Work Location:

In person