MDS Nurse (Registered Nurse)

About the role

This position is located at the Gallatin Rest Home and is responsible for coordinating and conducting periodic resident assessments and initiating and maintaining individualized care plans. The MDS Nurse ensures compliance with state and federal requirements for documentation, coding, and reporting under the Centers for Medicare & Medicaid Services (CMS) Patient Driven Payment Model (PDPM).

Responsibilities

• Coordinate completion of the Minimum Data Set (MDS) for each nursing home resident assessment in accordance with CMS requirements.
• Review resident charts for nursing, therapy, physician, and interdisciplinary team (IDT) documentation and assessments; conduct resident and staff interviews to collect and verify required information.
• Determine the appropriate assessment type (e.g., 5-day, Interim Payment Assessment, or Discharge) based on resident history and CMS PDPM guidelines.
• Complete MDS assessment reports, incorporating all collected data, and interpret and apply instructions as outlined in the CMS MDS Manual.
• Initiate, coordinate, and update resident care area narrative assessments and care plans to ensure compliance with timelines and regulations.
• Review charts and MDS data, conduct interviews, and develop preliminary care plans with problem statements, goals, and interventions; distribute to care team members for input and approval.
• Participate in Medicare Utilization Review meetings to assess current treatment plans, coordinate with administration and therapy staff, and recommend modifications as needed.
• Organize and coordinate care conferences, including notifying participants, reviewing electronic health records (EHR) for medication or care concerns, and documenting conference notes.
• Review and process medical records for approved admissions; compile appropriate documentation for resident charts.
• Enter admission orders into the EHR and evaluate for completeness, contraindications, or irregularities, report findings for correction or follow-up.
• Review pre-admission medical records to determine appropriate ICD-10 codes for active diagnoses and ensure coding accuracy in MDS entries to optimize PDPM reimbursement.
• Aid in staff education related to MDS accuracy, documentation standards, and care planning best practices as directed.
• Perform additional functions as assigned by the Rest Home Administrator.

Requirements

• Knowledge of: Human growth and development, nursing assessment, and long-term care best practices.
• Medical terminology, documentation standards, and the MDS assessment process.
• Medicare and Medicaid reimbursement systems, including PDPM and RUG methodologies.
• CMS and state regulations governing long-term care facilities.
• Care planning, interdisciplinary coordination, and resident-centered care approaches.

Skills

• Conducting accurate, detailed clinical assessments and interpreting complex medical data.
• Maintaining organized and compliant resident records and reports.
• Using electronic health record systems and related medical software.
• Communicating effectively with residents, staff, and medical professionals.
• Coordinating care and fostering collaboration within interdisciplinary teams.

Qualifications

• Bachelor’s degree in nursing from a National League of Nursing (NLN)-accredited program; and
• Current licensure as a Registered Nurse in the State of Montana;
• Minimum of three (3) years of related clinical experience; or An equivalent combination of education and experience that provides the required knowledge and skills.
• Certification as a Resident Assessment Coordinator (RAC-CT) preferred.