MDS Director

Position Summary

The MDS Director is responsible for coordinating and overseeing the Resident Assessment Instrument (RAI) process, including the completion and submission of the Minimum Data Set (MDS), Care Area Assessments (CAAs), and comprehensive care plans in accordance with CMS, OBRA, Medicare, Medicaid, and New Jersey Department of Health regulations. The MDS Director works collaboratively with the interdisciplinary team to ensure accurate resident assessments, maximize appropriate reimbursement, maintain regulatory compliance, and promote quality resident care.

Essential Duties and Responsibilities

MDS Coordination

Coordinate the timely completion of all OBRA, Medicare, Medicaid, PPS, IPA, Significant Change, Significant Correction, and Discharge MDS assessments.

Ensure all MDS assessments are completed accurately and submitted within required regulatory timeframes.

Review resident documentation to ensure MDS coding accurately reflects the resident's clinical condition.

Maintain the MDS schedule and assessment calendar.

Monitor Assessment Reference Dates (ARDs) to optimize reimbursement while maintaining regulatory compliance.

Care Planning

Coordinate interdisciplinary care plan meetings.

Develop, update, and revise individualized care plans based on resident assessments.

Ensure resident goals and interventions are appropriate and measurable.

Involve residents and families in the care planning process whenever appropriate.

Ensure care plans remain current and reflect changes in resident condition.

Clinical Reimbursement

Collaborate with therapy, nursing, dietary, social services, and other departments to ensure documentation supports appropriate reimbursement.

Review diagnoses, physician documentation, nursing documentation, therapy documentation, and supporting clinical records for accuracy.

Identify opportunities to improve documentation and reimbursement while maintaining regulatory compliance.

Participate in Medicare meetings and utilization reviews.

Monitor skilled coverage and payer requirements.

Regulatory Compliance

Maintain compliance with CMS, OBRA, Medicare, Medicaid, HIPAA, and New Jersey Department of Health regulations.

Ensure the RAI process complies with current CMS guidelines.

Remain current on changes to MDS coding requirements and reimbursement regulations.

Participate in state surveys and regulatory inspections.

Assist with Plans of Correction and regulatory follow-up as needed.

Quality Assurance

Conduct routine MDS audits to ensure coding accuracy.

Review Quality Measures (QMs) and Quality Reporting Program (QRP) data.

Identify trends affecting quality outcomes and reimbursement.

Participate in the facility's Quality Assurance and Performance Improvement (QAPI) program.

Recommend corrective actions to improve documentation and quality measures.

Interdisciplinary Collaboration

Work closely with Nursing, Therapy, Social Services, Dietary, Medical Records, Activities, and physicians.

Attend daily clinical meetings, Medicare meetings, and care conferences.

Communicate documentation deficiencies to department leaders.

Educate staff on documentation requirements related to MDS accuracy.

Documentation

Maintain accurate resident assessment records.

Ensure all supporting documentation is complete prior to MDS submission.

Monitor physician documentation to ensure consistency with MDS coding.

Review admission, transfer, discharge, and hospital return documentation for completeness.

Education

Educate nursing staff regarding documentation that supports accurate MDS coding.

Provide ongoing education regarding CMS updates and reimbursement changes.

Assist in training new nursing and interdisciplinary staff regarding the MDS process.

Qualifications

Current New Jersey RN license preferred; LPN may be considered in accordance with state regulations and facility policy.

Minimum of 2–3 years of clinical nursing experience , preferably in a skilled nursing facility.

Previous MDS Coordinator or Resident Assessment Coordinator experience preferred.

RAC-CT certification preferred but not required.

Thorough knowledge of the RAI Manual, MDS 3.0, PDPM, Medicare, Medicaid, OBRA, and CMS regulations.

Experience with electronic medical records, preferably PointClickCare.

Knowledge, Skills, and Abilities

Strong knowledge of MDS coding guidelines and reimbursement principles.

Excellent assessment and critical thinking skills.

Strong organizational and time management abilities.

Ability to analyze clinical documentation for accuracy and completeness.

Excellent written and verbal communication skills.

Ability to work collaboratively with an interdisciplinary team.

Proficiency with Microsoft Office and electronic health record systems.