MDS Coordinator

MDS Coordinator Job Description

Job Title: Minimum Data Set (MDS) Coordinator

Reports To: Director of Nursing (DON) / Administrator

Position Summary:
The MDS Coordinator is responsible for coordinating and completing the Resident Assessment Instrument (RAI) process, including Minimum Data Set (MDS) assessments, care planning, and compliance with federal and state regulations. This role ensures accurate clinical documentation, reimbursement optimization, and quality resident care in skilled nursing facilities and long-term care settings.

Key Responsibilities

MDS Assessment & Documentation

• Coordinate and complete MDS assessments according to regulatory timelines.
• Ensure accurate and comprehensive resident assessments.
• Review medical records to validate assessment data and supporting documentation.
• Submit MDS assessments to regulatory agencies within required deadlines.
• Monitor assessment schedules and maintain compliance with Medicare and Medicaid requirements.

Care Planning

• Develop, coordinate, and update individualized care plans based on resident assessments.
• Facilitate interdisciplinary care plan meetings.
• Ensure care plans reflect residents' current needs, goals, and preferences.
• Communicate assessment findings to nursing staff, physicians, therapists, and other healthcare professionals.

Regulatory Compliance

• Maintain compliance with Centers for Medicare & Medicaid Services (CMS) guidelines and state regulations.
• Participate in surveys, audits, and quality assurance activities.
• Stay current on MDS, RAI, and reimbursement regulations and updates.
• Educate staff regarding documentation standards and regulatory requirements.

Reimbursement & Case Management

• Support Medicare and Medicaid reimbursement processes through accurate coding and assessment.
• Review documentation for appropriate Resource Utilization Group (RUG) or Patient-Driven Payment Model (PDPM) classification.
• Collaborate with billing and finance departments to maximize reimbursement while maintaining compliance.
• Monitor quality measures and identify opportunities for improvement.

Quality Improvement

• Analyze quality indicators and quality measures.
• Participate in performance improvement initiatives.
• Assist with infection control, risk management, and resident outcome monitoring as needed.

Qualifications

• Active Registered Nurse (RN) license; some facilities may consider LPN/LVN candidates.
• Certification such as RAC-CT preferred.
• Minimum 1–3 years of experience in long-term care, skilled nursing, or rehabilitation.
• Strong knowledge of MDS 3.0, RAI process, CMS regulations, and PDPM.
• Proficiency in electronic health records (EHR) systems.
• Excellent organizational, analytical, and communication skills.

Required Skills

• Clinical assessment and documentation
• MDS coding accuracy
• Care planning and coordination
• Regulatory compliance knowledge
• Time management and attention to detail
• Data analysis and quality improvement
• Team collaboration and leadership

Physical Requirements

• Ability to sit, stand, walk, and use a computer for extended periods.
• Ability to review detailed clinical documentation.
• Occasional lifting, bending, and assisting with resident assessments as needed.