Registered Nurse / MDS Coordinator

Overview
We are seeking a dedicated and detail-oriented Registered Nurse / MDS Coordinator to join our healthcare team. In this vital role, you will oversee the comprehensive assessment and documentation of patient care needs, ensuring compliance with regulatory standards such as NCQA (National Committee for Quality Assurance) and Medicare requirements. Your expertise will drive clinical documentation improvement, facilitate accurate coding, and support optimal patient outcomes in a long-term care setting. This position offers an exciting opportunity to impact patient care quality while working with an advanced EMR (Electronic Medical Record) system. Your leadership in managing MDS (Minimum Data Set) processes will be instrumental in maintaining high standards of health information management and medical documentation accuracy.

Duties

• Lead the completion and review of MDS assessments to ensure accurate reflection of patient conditions, supporting quality metrics and reimbursement processes.
• Collaborate with interdisciplinary teams—including nursing, therapy, social work, and medical staff—to develop individualized care plans aligned with clinical documentation improvement initiatives.
• Ensure compliance with HIPAA regulations by safeguarding patient information during documentation review and data entry processes.
• Utilize EMR to document patient data accurately and efficiently.
• Conduct utilization review and utilization management activities to optimize resource use while maintaining compliance with Medicare, Medicaid, and managed care standards.
• Perform coding using ICD-10/ICD-9/ICD coding conventions and CPT coding procedures to support billing accuracy and reimbursement efforts.
• Coordinate discharge planning and case management activities for inpatient, outpatient, hospice, or home care patients to facilitate smooth transitions of care.
• Maintain thorough medical records and ensure all documentation aligns with NCQA standards for quality assurance.
• Support clinical staff with physiology knowledge, medical terminology clarification, and medical records management to enhance overall patient care delivery.

Requirements

• Valid Registered Nurse (RN) license with current state licensure required.
• Proven experience in MDS coordination within a skilled nursing facility or long-term care environment preferred.
• Strong knowledge of ICD-10/ICD-9/ICD coding systems, CPT coding procedures, and DRG (Diagnosis-Related Group) classifications.
• Critical care experience including ICU or Level I/II trauma center exposure is highly desirable.
• Knowledge of HIPAA regulations related to medical records confidentiality and security protocols.
• Excellent organizational skills with attention to detail for documentation review and medical records management.
• Ability to work collaboratively across multidisciplinary teams in fast-paced healthcare settings.
• Strong understanding of anatomy, physiology, medical terminology, and clinical documentation improvement strategies. Join our team to make a meaningful difference in patient outcomes through expert documentation management and clinical coordination!

Pay: From $34.00 per hour

Benefits:

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

Work Location: In person

Salary : $34