Job Summary We are seeking a dedicated and highly skilled MDS Coordinator/ADON to join our dynamic healthcare team. In this vital role, you will oversee the comprehensive assessment and documentation of patient care needs, ensuring compliance with federal and state regulations, including Medicare and Medicaid requirements. Your leadership will drive clinical documentation improvement, coordinate interdisciplinary care plans, and support quality initiatives to enhance patient outcomes. This position offers an exciting opportunity for a motivated professional to make a meaningful impact in long-term care, acute care, or hospital settings while fostering a culture of excellence and compassionate patient care. Duties Lead the development and implementation of Minimum Data Set (MDS) assessments, ensuring accuracy and timeliness in accordance with CMS (Centers for Medicare and Medicaid Services) standards. Oversee clinical documentation review to ensure compliance with health regulation policies, HIPAA, and clinical documentation standards. Collaborate with interdisciplinary teams—including nursing, therapy, social services, and medical staff—to coordinate discharge planning, case management, and patient care strategies. Manage electronic health records (EHR/EHR systems such as Cerner, Epic, Athenahealth, eClinicalWorks) to facilitate accurate medical records documentation and coding. Conduct utilization management and review processes to optimize patient care delivery while adhering to Medicare regulations and long-term care guidelines. Provide leadership as an Assistant Director of Nursing (ADON), supporting nursing staff in clinical practices related to acute care experience, ICU or PICU experience, or hospital environments. Ensure compliance with all applicable health regulation policies including CMS guidelines, NCQA standards, HIPAA privacy rules, and state healthcare regulations. Facilitate staff training on medical terminology, ICD-10/ICD coding (including CPT coding), DRG assignment, and documentation review processes. Support quality improvement initiatives by analyzing clinical data related to medical management, case management, and documentation accuracy. Assist in managing EMR/EHR systems such as Meditech or Athenahealth for efficient healthcare delivery and recordkeeping. Skills Extensive knowledge of Epic EMR/EHR systems and other electronic health record platforms like Cerner or eClinicalWorks. Strong understanding of Medicare regulations, long-term care regulations, ICD-10/ICD coding including CPT codes for outpatient procedures. Proven experience in utilization review, clinical documentation improvement (CDI), and medical coding processes. Critical care experience in ICU or Level I/II trauma centers is highly desirable. Familiarity with hospital-based inpatient/outpatient settings as well as nursing home or hospice environments. Excellent leadership skills with the ability to guide interdisciplinary teams effectively. Proficiency in Microsoft Office suite for reporting and data analysis purposes. Knowledge of physiology, anatomy, medical terminology, and health information management standards. Strong understanding of HIPAA compliance and patient privacy protocols across healthcare settings. Ability to interpret complex clinical data to support case management decisions while ensuring adherence to CMS guidelines. Join us in delivering exceptional patient-centered care through expert clinical documentation management! This role is paid and offers a rewarding environment where your expertise directly contributes to improved health outcomes while supporting your professional growth within a vibrant healthcare organization.

Pay:

$30.00 - $34.00 per hour

Benefits:

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

Work Location:

In person