MDS Registered Nurse

Job Summary

We are seeking a dedicated and detail-oriented MDS Registered Nurse to join our healthcare team. In this vital role, you will lead the comprehensive assessment and documentation of residents' clinical conditions, ensuring compliance with federal and state regulations. Your expertise will support care planning, quality improvement initiatives, and reimbursement processes. The ideal candidate is passionate about patient care, possesses strong clinical documentation skills, and has experience working within long-term care or inpatient settings. This position offers an exciting opportunity to make a meaningful impact on resident outcomes while advancing your nursing career.

Responsibilities

• Conduct thorough Minimum Data Set (MDS) assessments in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines to evaluate residents’ health status and functional abilities.
• Review medical records, clinical documentation, and care plans to ensure accuracy, completeness, and compliance with healthcare regulations such as HIPAA and long-term care standards.
• Collaborate with interdisciplinary teams—including nursing staff, physicians, social workers, and therapy providers—to develop individualized care plans based on assessment findings.
• Utilize electronic health record (EHR) Point Click Care to document assessments, coding data (CPT, ICD-9/10), and update resident records efficiently.
• Perform utilization management and review medical documentation to support appropriate reimbursement under Medicare and Medicaid programs.
• Ensure adherence to clinical documentation standards, coding accuracy (including DRG assignments), and regulatory policies related to long-term care.
• Participate in quality assurance activities, including clinical documentation improvement initiatives and compliance audits aligned with NCQA standards.

Requirements

• Valid Registered Nurse (RN) license in good standing with current state registration.
• Proven experience with MDS assessments in long-term care facilities or inpatient hospital environments.
• Strong knowledge of CMS regulations, Medicare/Medicaid policies, HIPAA compliance, and state healthcare regulations governing medical records and documentation.
• Familiarity with electronic health record (EHR) systems such as Point Click Care, proficiency in Microsoft Office is a plus.
• Expertise in medical coding including ICD-9/10 coding systems, CPT coding, DRG assignments, and utilization review processes.
• Excellent understanding of anatomy, physiology, medical terminology, and clinical documentation standards necessary for accurate assessments.
• Ability to review complex medical records critically while maintaining attention to detail; experience with home care or hospice is advantageous.
• Strong communication skills for collaborating across disciplines and ensuring compliance with healthcare policies related to Medicare regulations and long-term care standards.

Join our team as an MDS Registered Nurse if you are eager to leverage your clinical expertise in a dynamic environment dedicated to delivering exceptional resident care while advancing your professional growth!

Pay: From $32.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $32