MDS Coordinator (RN)

MDS Coordinator

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 include coordinating the facility's MDS/RAI process and ensuring assessments are completed accurately and within required timeframes; completing and coordinating OBRA and PPS assessments in accordance with applicable regulations and facility policies; reviewing resident medical records, clinical documentation, therapy records, nursing documentation, physician documentation, and other supporting information to ensure accurate assessment coding; coordinating with interdisciplinary team members to obtain accurate information for MDS completion; facilitating and/or coordinating the completion of the Care Area Assessment (CAA) process and development of appropriate care plans; ensuring significant changes in resident condition are identified and appropriately addressed; monitoring MDS schedules, assessment reference dates, ARDs, completion dates, and submission deadlines; verifying MDS assessments for accuracy, completeness, and consistency prior to submission; identifying discrepancies or incomplete documentation and working with appropriate departments to resolve them; coordinating with the Business Office, therapy department, nursing, and other departments regarding reimbursement-related documentation and resident classification; participating in interdisciplinary care plan meetings and ensuring care plans are consistent with MDS findings and resident needs; monitoring changes in resident condition and communicating significant findings to the DON and interdisciplinary team; assisting with maintaining accurate supporting documentation for MDS items and clinical reimbursement; monitoring facility MDS reports and identifying trends, missed assessments, documentation concerns, and potential compliance issues; maintaining current knowledge of CMS, RAI Manual, Medicare/Medicaid, and applicable Alabama requirements affecting the MDS process; assisting with survey preparation and responding appropriately to requests for MDS and clinical documentation; participating in quality assurance and performance improvement (QAPI) activities related to clinical documentation, MDS accuracy, resident outcomes, and reimbursement; educating nursing and interdisciplinary staff regarding MDS documentation requirements and changes in the RAI process; maintaining confidentiality of resident information in accordance with HIPAA and facility policies; and performing other duties as assigned by the DON and/or Administrator.

Qualifications include a current Alabama nursing license as an RN or LPN/LVN, 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; and proficiency with electronic medical records and MDS software systems.

Preferred experience includes 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, and familiarity with the current CMS RAI User's Manual and MDS requirements.

Physical requirements 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.