MDS Nurse

GENERAL DESCRIPTION:

MDS (Minimum Data Set) nurse collects and assesses information for the health and well-being resident in Medicare or Medicaid-certified beds.  Complies with Federal and State requirements for all MDS sections.  Follows facility policy and procedures.  The MDS Nurse monitors residents’ health and well-being from the time of admission through the end of their stay.  Assist with Quality Assurance and quality measures.

DUTIES AND RESPONSIBILITIES:  (Include, but are not limited to, the following.)

1. Completes the nursing components of the Resident Assessment Instrument (RAI) process to ensure timely completion of Minimum Data Set.
2. Ensures completion of PPS and/or OBRA assessments for both subacute and long-term care as required.
3. Collaborates with the resident, family or advocate, other inter-disciplinary colleagues, including providers, to assure ongoing care of each resident is provided for the best quality of life possible.
4. The MDS Nurse uses independent judgment in the planning, organizing, directing, and evaluation of activities of the professional and supportive nursing staff engaged in resident plan of care.
5. The MDS Nurse utilizes State and Federal guidelines for the RAI process ensuring documentation meets necessary guidelines and reimbursement standards.
6. Signs the MDS forms to signify completion of the process.
7. Reviews validity of MDS responses from all disciplines.
8. Ensure timely completion and accuracy of MDS assessments.
9. Work with HIM Director and Quality Care Coordinator to conduct concurrent MDS reviews to assure achievement of maximum allowable RUG categories.
10. Gathers information from nursing, dietary, social services, therapy, and physician services to ensure appropriate quality of care and  reimbursement.
11. Other duties as assigned by Director of Health Information. 
12. As needed, the MDS Nurse will assist with completing nursing assessments and the development of a written plan of care for each resident that identifies the problems/needs of the resident, indicates the care given, goals to be accomplished and which professional service is responsible for each element of care.
13. Ensure legal compliance for the facility by following the MDS Process.
14. Assists with determination coverage for skilled Nursing services and provide. complete team with documentation information to prevent payment denials.
15. Utilizes the RAI, MDS 3.0, QM and QRP manuals to ensure the highest quality of care is provided, documentation supports outcomes and maximum reimbursement is achieved.
16. Review 24-hour report for updates and possible change of condition.
17. Assists with the Quality Assurance Program as needed.
18. Must be able to work more than either eight (8) hours per day or more than forty (40) hours per week.

QUALIFICATIONS:

• Current NYS Licensed Registered Nurse
• Knowledge of MDS 3.0, CAA’s, Medicare and Medicaid Guidelines for coverage and reimbursement
• Excellent written and oral communication skills with the ability to work independently and under time constraints
• Long-Term Care Experience helpful but not necessary.
• Basic computer skills