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 Overview We are seeking a dedicated and detail-oriented MDS Nurse to join our healthcare team, specializing in the comprehensive assessment and coordination of care for patients in skilled nursing facilities, long-term care, or inpatient rehabilitation settings. As an MDS Nurse, you will play a vital role in ensuring accurate clinical documentation, compliance with regulatory standards, and optimal patient outcomes. Your expertise in medical coding, utilization review, and clinical documentation improvement will drive quality care delivery and support reimbursement processes. This position offers an exciting opportunity to make a meaningful impact on patient care through meticulous assessment and interdisciplinary collaboration. Duties Conduct thorough assessments of patient conditions using clinical data to complete Minimum Data Set (MDS) assessments aligned with federal and state regulations. Review medical records, documentation, and physician notes to ensure accuracy and completeness for reimbursement and quality reporting. Collaborate with interdisciplinary teams including nursing staff, physicians, social workers, and therapists to develop individualized care plans. Perform utilization review and management activities to optimize patient care pathways while ensuring compliance with Medicare, Medicaid, and other managed care programs. Utilize EMR (Electronic Medical Record) systems such as Epic, Cerner, or Athenahealth to document assessments, updates, and care plans efficiently. Maintain knowledge of
ICD-10/ICD-9
coding standards, CPT coding procedures, DRG (Diagnosis-Related Group) classifications, and medical terminology to support accurate documentation. Support discharge planning processes by coordinating post-acute care services such as hospice or home care when appropriate. Ensure adherence to HIPAA regulations by safeguarding patient information during all documentation review activities. Qualifications Registered Nurse (RN) or Licensed Vocational Nurse license with current state licensure required. Proven experience in acute care settings such as
ICU, LTC.
Strong knowledge of Medicare regulations, NCQA standards, ICD coding (ICD-10/ICD-9), CPT coding, DRG classifications, and utilization management principles. Experience with EMR/EHR systems including Epic, Cerner, Athenahealth, or eClinicalWorks preferred. Background in medical documentation review, clinical data analysis, and healthcare compliance is essential. Familiarity with managed care environments and case management principles enhances success in this role. Excellent understanding of physiology, anatomy, medical terminology, and patient care practices across inpatient and outpatient settings. Prior nursing home experience or work within a Level I or Level II trauma center is advantageous. Ability to interpret complex medical records accurately while maintaining attention to detail under tight deadlines. Join our team as an MDS Nurse to leverage your clinical expertise in a dynamic environment committed to delivering exceptional patient-centered care!
