MDS Registered Nurse Crown Pointe of Carmel - 3.0 Council Bluffs, IA Job Details Full-time 1 hour ago Benefits Health insurance Dental insurance Paid time off Vision insurance Qualifications Collaborate with healthcare professionals Anatomy knowledge Teamwork Utilization review RN License Coding for hospital billing HIPAA Care documentation Acute care facility experience Electronic health record (EHR) management for billing and coding Utilization management Resource utilization in healthcare Health information regulatory compliance Multidisciplinary team collaboration for treatment planning Clinical documentation improvement Health information management Medical data abstraction Clinical confidentiality policies Clinical documentation standards Managing patient records Medical terminology Medical record review for billing accuracy Documentation review for coding accuracy Full Job Description Overview Join our dynamic healthcare team as a Medical Data Systems (MDS) Registered Nurse, where your expertise will drive excellence in patient care documentation and regulatory compliance. In this vital role, you will utilize your comprehensive nursing background and clinical documentation skills to ensure accurate, timely, and compliant medical records. Your proactive approach will support quality care delivery, streamline utilization management, and uphold the highest standards of healthcare regulation adherence. This position offers an exciting opportunity to make a meaningful impact within a collaborative environment dedicated to patient-centered outcomes. Duties Conduct thorough reviews of medical records to ensure compliance with clinical documentation standards and healthcare regulations such as CMS, HIPAA, and state-specific policies. Utilize EMR/EHR systems including Epic, Cerner, Athenahealth, and eClinicalWorks to document, update, and manage patient information efficiently. Perform comprehensive utilization review and management by analyzing patient data to support appropriate level of care decisions, including discharge planning and case management. Apply CPT coding, ICD-9/10 coding, DRG assignment, and HEDIS measures to facilitate accurate medical documentation and billing processes. Collaborate with interdisciplinary teams to improve clinical documentation improvement (CDI), ensuring accurate reflection of patient care activities and physiology knowledge. Assist in medical records review for inpatient and outpatient settings, including long-term care facilities, hospitals, ICU, PICU, trauma centers, hospice care, and emergency medicine environments. Maintain strict adherence to health regulation policies such as Medicare regulations, NCQA standards, CMS guidelines, and long-term care regulations while ensuring compliance with HIPAA privacy rules. Requirements Valid RN license with current registration in the applicable state. Proven experience in acute care settings such as ICU, emergency medicine, or trauma centers; hospital experience preferred. Strong knowledge of medical terminology, anatomy, physiology, and clinical documentation standards. Proficiency in EMR/EHR systems including Epic, Cerner, Athenahealth or similar platforms; experience with Microsoft Office is a plus. Familiarity with medical coding (CPT, ICD-9/10), DRG assignment, utilization management processes and health information management practices. Prior experience with managed care organizations or Medicare/Medicaid regulations is highly desirable. Excellent attention to detail with strong analytical skills for documentation review and compliance monitoring. Ability to work effectively within multidisciplinary teams while maintaining confidentiality under HIPAA guidelines. Embark on a rewarding career where your nursing expertise fuels quality improvement initiatives and enhances patient outcomes through precise medical documentation!

Benefits:

Dental insurance Health insurance Paid time off Vision insurance

Work Location:

In person