A Registered Nurse provides medical care and treatment, educates patients about their conditions, and provides emotional support to patients and families. Works in hospitals, schools, clinics or community health centers. Works under the supervision of a physician or other specialist, and serves as the primary point of care for patients in a hospital setting. May specialize in emergency room work, or treatment for a particular condition, or specialize in working with infants, the elderly or other patient groups. May work as an advanced practice specialists and prescribe medications in addition to offering specialty care.
Job Summary We are seeking a dedicated and highly skilled MDS Registered Nurse to join our healthcare team. The ideal candidate will possess extensive experience in clinical documentation, utilization review, and case management within inpatient and outpatient settings. As an MDS Registered Nurse, you will be responsible for conducting comprehensive assessments, ensuring accurate medical documentation, and facilitating compliance with regulatory standards such as Medicare and NCQA. Your expertise in medical coding, health information management, and patient care will contribute to optimal clinical outcomes and quality of care delivery. Responsibilities Conduct thorough Minimum Data Set (MDS) assessments for residents or patients to evaluate their functional status and care needs in accordance with federal and state regulations. Review medical records, clinical documentation, and coding to ensure accuracy and completeness, including
ICD-10/ICD-9/ICD
coding and CPT coding where applicable. Collaborate with interdisciplinary teams to develop individualized care plans, discharge planning strategies, and optimize patient outcomes. Perform utilization review and management activities to ensure appropriate level of care, resource utilization, and compliance with Medicare and other payer requirements. Maintain detailed documentation within Electronic Health Record (EHR) systems such as Cerner, Epic, Athenahealth, or eClinicalWorks to support clinical decision-making and regulatory audits. Participate in clinical documentation improvement initiatives to enhance accuracy of medical records and support reimbursement processes like DRG (Diagnosis-Related Group) assignment. Ensure compliance with HIPAA regulations by safeguarding patient information during documentation review and data handling processes. Support case management activities including discharge planning, hospice care coordination, or outpatient services as needed across various healthcare settings such as hospitals, nursing homes, or home care environments. Requirements Valid Registered Nurse (RN) license with current state licensure. Proven experience working in inpatient settings such as Level I or Level II trauma centers, ICU/PICU units, or emergency medicine environments. Strong knowledge of clinical documentation improvement (CDI), utilization review, utilization management, and health information management principles. Familiarity with EMR/EHR systems including Cerner, Epic, Athenahealth, or eClinicalWorks; experience with medical records review is essential. Expertise in medical terminology, anatomy/physiology knowledge, ICD coding (ICD-10/ICD-9), CPT coding, DRG assignment, and Medicare regulations. Prior experience in managed care environments or hospital settings with a focus on acute care or outpatient services preferred. Excellent organizational skills with attention to detail; ability to handle multiple priorities efficiently while maintaining accuracy. Strong communication skills for effective collaboration with interdisciplinary teams and external agencies involved in patient care coordination. Join our team as an MDS Registered Nurse to make a meaningful impact on patient outcomes through precise documentation, efficient case management, and adherence to regulatory standards!
Pay:
$37.83 - $45.55 per hour
Benefits:
Dental insurance Health insurance Paid time off Vision insurance
