MDS Coordinator (RN)

Job Description

Job Description

Description:

Department:

Nursing Reports To:

Director of Nursing (DON) / Administrator Status:

Full-Time

Position Summary

The MDS Coordinator is responsible for coordinating and overseeing the facility’s Resident Assessment Instrument (RAI) process, including the completion and submission of accurate and timely Minimum Data Set (MDS) assessments. This position works collaboratively with nursing, therapy, dietary, social services, activities, medical providers, and other interdisciplinary team members to ensure residents receive appropriate care and that assessments accurately reflect each resident’s clinical condition and care needs.

The MDS Coordinator is responsible for maintaining compliance with applicable

CMS, Medicare/Medicaid, Alabama Department of Public Health (ADPH), and facility requirements

related to the MDS/RAI process. Essential Duties and Responsibilities

Coordinate the facility’s MDS/RAI process and ensure assessments are completed accurately and within required timeframes. Complete and coordinate OBRA and PPS assessments in accordance with applicable regulations and facility policies. Review resident medical records, clinical documentation, therapy records, nursing documentation, physician documentation, and other supporting information to ensure accurate assessment coding. Coordinate with interdisciplinary team members to obtain accurate information for MDS completion. Facilitate and/or coordinate the completion of the Care Area Assessment (CAA) process and development of appropriate care plans. Ensure significant changes in resident condition are identified and appropriately addressed. Monitor MDS schedules, assessment reference dates, ARDs, completion dates, and submission deadlines. Verify MDS assessments for accuracy, completeness, and consistency prior to submission. Identify discrepancies or incomplete documentation and work with appropriate departments to resolve them. Coordinate with the Business Office, therapy department, nursing, and other departments regarding reimbursement-related documentation and resident classification. Participate in interdisciplinary care plan meetings and ensure care plans are consistent with MDS findings and resident needs. Monitor changes in resident condition and communicate significant findings to the DON and interdisciplinary team. Assist with maintaining accurate supporting documentation for MDS items and clinical reimbursement. Monitor facility MDS reports and identify trends, missed assessments, documentation concerns, and potential compliance issues. Maintain current knowledge of CMS, RAI Manual, Medicare/Medicaid, and applicable Alabama requirements affecting the MDS process. Assist with survey preparation and respond appropriately to requests for MDS and clinical documentation. Participate in quality assurance and performance improvement (QAPI) activities related to clinical documentation, MDS accuracy, resident outcomes, and reimbursement. Educate nursing and interdisciplinary staff regarding MDS documentation requirements and changes in the RAI process. Maintain confidentiality of resident information in accordance with HIPAA and facility policies. Perform other duties as assigned by the DON and/or Administrator. Qualifications

Current Alabama nursing license as an

RN

, as required by facility policy and applicable regulations. Previous experience in skilled nursing, long-term care, or post-acute healthcare preferred. Previous MDS Coordinator experience preferred. Knowledge of the CMS RAI/MDS process and long-term care regulations. Knowledge of Medicare and Medicaid reimbursement principles preferred. Strong clinical assessment and documentation skills. Excellent organizational and time-management skills. Ability to meet strict assessment and submission deadlines. Strong communication and interdisciplinary collaboration skills. Ability to identify inconsistencies in clinical documentation and obtain clarification when necessary. Proficiency with electronic medical records and MDS software systems. Preferred Experience

1–2 years of MDS experience preferred. Experience with Medicare Part A and managed care reimbursement. Experience with care planning and interdisciplinary team meetings. Experience preparing for state or federal surveys. Familiarity with the current CMS RAI User’s Manual and MDS requirements. Physical Requirements

The employee must be able to perform the essential functions of the position. Requirements may include frequent sitting, standing, walking throughout the facility, bending, reaching, lifting, and accessing resident records and clinical documentation. Reasonable accommodations may be made for qualified individuals with disabilities. Compliance

The MDS Coordinator is expected to perform all responsibilities in accordance with applicable

federal and Alabama laws and regulations, CMS requirements, Alabama Department of Public Health requirements, HIPAA, facility policies, and professional standards of practice.

Requirements: Qualifications

Current Alabama nursing license as an

RN

, as required by facility policy and applicable regulations. Previous experience in skilled nursing, long-term care, or post-acute healthcare preferred. Previous MDS Coordinator experience preferred. Knowledge of the CMS RAI/MDS process and long-term care regulations. Knowledge of Medicare and Medicaid reimbursement principles preferred. Strong clinical assessment and documentation skills. Excellent organizational and time-management skills. Ability to meet strict assessment and submission deadlines. Strong communication and interdisciplinary collaboration skills. Ability to identify inconsistencies in clinical documentation and obtain clarification when necessary. Proficiency with electronic medical records and MDS software systems. Preferred Experience

2 years of MDS experience preferred. Experience with Medicare Part A and managed care reimbursement. Experience with care planning and interdisciplinary team meetings. Experience preparing for state or federal surveys. Familiarity with the current CMS RAI User’s Manual and MDS requirements. Physical Requirements

The employee must be able to perform the essential functions of the position. Requirements may include frequent sitting, standing, walking throughout the facility, bending, reaching, lifting, and accessing resident records and clinical documentation. Reasonable accommodations may be made for qualified individuals with disabilities.

The MDS Coordinator is expected to perform all responsibilities in accordance with applicable

federal and Alabama laws and regulations, CMS requirements, Alabama Department of Public Health requirements, HIPAA, facility policies, and professional standards of practice.