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.)

• Completes the nursing components of the Resident Assessment Instrument (RAI) process to ensure timely completion of Minimum Data Set.

• Ensures completion of PPS and/or OBRA assessments for both subacute and long-term care as required.

• 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.

• 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.

• The MDS Nurse utilizes State and Federal guidelines for the RAI process ensuring documentation meets necessary guidelines and reimbursement standards.

• Signs the MDS forms to signify completion of the process.

• Reviews validity of MDS responses from all disciplines.

• Ensure timely completion and accuracy of MDS assessments.

• Work with HIM Director and Quality Care Coordinator to conduct concurrent MDS reviews to assure achievement of maximum allowable RUG categories.

• Gathers information from nursing, dietary, social services, therapy, and physician services to ensure appropriate quality of care and reimbursement.

• Other duties as assigned by Director of Health Information .

• 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.

• Ensure legal compliance for the facility by following the MDS Process.

• Assists with determination coverage for skilled Nursing services and provide. complete team with documentation information to prevent payment denials.

• 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.

• Review 24-hour report for updates and possible change of condition.

• Assists with the Quality Assurance Program as needed.

• 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