Minimum Data Set Specialist

Clinical Documentation Coordinator

Coordinates assessment of patients/residents to comply with Centers for Medicare and Medicaid Services (CMS) and Department of Health requirements, assessing residents for Medicare and managed care benefits. Ensures continuous maintenance of Minimum Data Set (MDS) computer-records. Ensures the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care.

Job Responsibility

• Coordinates and ensures completion of interdepartmental MDS for new, readmitted, quarterly, and annual reviews, and significant-change-of-status residents/patients according to required Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment System (PPS) schedules.
• Completes and/or assures completion of documentation for Medicare reimbursement.
• Reviews documentation of all disciplines and care plans to ensure regulatory compliance.
• Reports deficient assessments promptly to effect immediate improvement.
• Completes Resident Assessment Protocols (RAPS) for all patients/residents.
• Ensures the nursing process of assessment, diagnosis, outcome identification, planning, implementation and evaluation of patient care.
• Participates on admission committee and comprehensive care plan meetings; prepares and conducts staff training and on-going education for MDS documentation.
• Participates in performance improvement processes both within the facility and with transferring facilities to maximize reimbursement.
• May Chair the Comprehensive Care Plan (CCP).
• Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

• Graduate from an accredited School of Nursing required. Must obtain a Bachelor of Science in Nursing degree within 5 years of employment date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• 1-3 years of relevant experience, required.

*Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).