MDS Registered Nurse

MDS Registered Nurse Bethesda Health Care Facility - 3.2 Eastover, NC Job Details Full-time $38 - $40 an hour 10 hours ago Benefits Free parking Disability insurance Health insurance Dental insurance Paid time off Vision insurance Life insurance Retirement plan Qualifications

HIPAA ICD-10

Clinical documentation Health information management Medical terminology Full Job Description Job Overview We are seeking a dedicated and detail-oriented MDS Registered Nurse to join our healthcare team at our privately owned 85 bed facility. In this vital role, you will be responsible for conducting comprehensive assessments and coordinating care plans to ensure optimal patient outcomes within skilled nursing. Your expertise in clinical documentation, medical coding, and utilization review will support compliance with regulatory standards and enhance the quality of care delivery. This position offers an exciting opportunity to apply your nursing skills and health information management knowledge in a dynamic environment committed to excellence. Duties Perform thorough Minimum Data Set (MDS) assessments for residents or patients, ensuring accuracy and completeness in accordance with federal and state regulations. Review medical records, clinical documentation, and coding to facilitate accurate case management and reimbursement processes. Collaborate with interdisciplinary teams to develop individualized care plans that meet patient needs while adhering to NCQA standards and CMS guidelines. Conduct utilization review and management activities, including discharge planning, hospice care coordination, and acute care evaluations. Apply CPT coding, ICD-9/10 coding, DRG assignment, and medical terminology expertise to support accurate billing and compliance. Participate in clinical documentation improvement initiatives to enhance data quality and support medical management objectives. Maintain HIPAA compliance by safeguarding patient information during all documentation review processes. Skills Strong knowledge of physiology, anatomy, medical terminology, and health information management principles. Proficiency with EMR/EHR systems for documentation and record-keeping. Experience with managed care programs including Medicare and Medicaid regulations. Expertise in medical coding (CPT, ICD-9/10), DRG assignment, utilization review, and discharge planning processes. Knowledge of HIPAA regulations to ensure confidentiality and security of patient data. Excellent analytical skills for documentation review and medical records auditing; ability to interpret physiology and anatomy knowledge effectively. Effective communication skills for collaborating with multidisciplinary teams. Join our team as an MDS Registered Nurse where your expertise will directly impact patient care quality while supporting operational excellence! We are committed to fostering a vibrant work environment that values your skills in nursing, medical management, coding accuracy, and clinical documentation improvement—all within a paid position that recognizes your vital contributions!

Pay:

$38.00 - $40.00 per hour

Benefits:

Dental insurance Disability insurance Free parking Health insurance Life insurance Paid time off Retirement plan Vision insurance

Work Location:

In person