Job Overview We are seeking a dedicated and detail-oriented MDS Registered Nurse to join our healthcare team. In this vital role, you will lead the comprehensive assessment and documentation of residents' health status using the Minimum Data Set (MDS) process, ensuring compliance with federal and state regulations. Your expertise will support optimal patient care, accurate clinical documentation, and effective utilization management. This position offers an exciting opportunity to make a meaningful impact in long-term care, skilled nursing facilities, or hospital settings by coordinating interdisciplinary care plans and ensuring adherence to healthcare standards. Responsibilities Conduct thorough MDS assessments in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines, ensuring accurate data collection on residents' physical, psychological, and social functioning. Review medical records, clinical documentation, and health information to verify completeness and compliance with clinical documentation standards. Collaborate with interdisciplinary teams including physicians, therapists, social workers, and case managers to develop individualized care plans based on assessment findings. Ensure timely completion of all MDS items, including CPT coding, ICD-9/ICD-10 coding, DRG (Diagnosis-Related Group) assignments, and HEDIS measures for quality reporting. Monitor changes in residents' condition to update assessments accordingly and support discharge planning or transition of care processes such as hospice or emergency medicine referrals. Maintain proficiency with EMR/EHR systems like Point Click Care. Stay current with healthcare regulations including HIPAA, long-term care regulations, Medicare regulations, and NCQA standards to ensure ongoing compliance. Requirements Valid RN license with current registration in the applicable state. Proven experience with MDS processes within long-term care facilities or hospital inpatient settings. Strong knowledge of clinical documentation improvement practices and medical terminology related to physiology and anatomy. Familiarity with ICD coding (ICD-9/ICD-10), CPT coding, DRG assignment, and utilization review procedures. Experience working with EMR/EHR systems such Point Click Care Knowledge of Medicare/Medicaid policies, CMS regulations, and discharge planning protocols. Excellent communication skills for effective collaboration across multidisciplinary teams and documentation review processes. Ability to manage multiple priorities efficiently while maintaining attention to detail in a fast-paced environment. Join our team to play a crucial role in delivering exceptional patient care through precise assessment and meticulous documentation! We are committed to supporting your professional growth while ensuring you have the resources needed to excel in this dynamic role.

Benefits:

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

Work Location:

In person