Job Description

Mission Statement

Senior communities of care inspiring mind, body, and soul.

Vision Statement

To be premier communities committed to excellence of care through grace, compassion, and respect.

General Statement of Duties

The MDS Coordinator – RN leads and coordinates the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) process for the community in accordance with current Centers for Medicare & Medicaid Services (CMS) requirements, the current RAI User’s Manual, applicable Indiana or Ohio requirements, and organizational standards. The position ensures assessments, Care Area Assessments (CAAs), care planning, supporting documentation, submissions, and corrections are accurate, complete, timely, and coordinated with the interdisciplinary team. The MDS Coordinator – RN also supports accurate reimbursement, quality reporting, survey readiness, and staff education while protecting resident-centered care and data integrity. In keeping with CMS requirements, the RN conducts or coordinates resident assessments with appropriate participation of health professionals and completes RN-required certification responsibilities.

Essential Job Duties and Responsibilities

• Maintain the community MDS schedule and conduct or coordinate timely completion or required OBRA and Medicare assessments, reviews, discharge assessments, corrections, and related RAI activities using the current CMS RAI User’s Manual and applicable regulatory timeframes.
• Coordinate resident interviews, observations, record review, and interdisciplinary input; ensure each discipline completes assigned MDS items accurately, within required timeframes, and with required attestations or signatures.
• Review the completed assessment for internal consistency, supporting documentation, coding accuracy, and completion requirements; sign and certify RN-required assessment completion and coordinate corrections or modifications when errors are identified.
• Coordinate the RAI process with nursing, therapy, dietary, social services, activities, pharmacy, providers, and other disciplines so assessment findings are translated into individualized, resident-centered care planning within required timeframes.
• Support completion and documentation of Care Area Assessments and care-plan updates based on resident strengths, needs, preferences, goals, risks, and significant changes; ensure the care plan is consistent with the assessment and supporting clinical record.
• Promote resident and representative participation in the assessment and care-planning process and communicate significant assessment findings, discrepancies, or care concerns promptly to the Director of Nursing and appropriate interdisciplinary team members.
• Apply current RAI coding guidance, ICD-10-CM conventions as applicable to assigned responsibilities, and Medicare payment methodology requirements, including PDPM-related MDS elements, while ensuring coding is supported by the clinical record and is not driven solely by reimbursement outcomes.
• Montior MDS-related reimbursement and quality data for accuracy and trends, collaborate with billing, therapy, nursing, and other departments to resolve documentation or coding discrepancies, and elevate concerns that may affect payment, compliance, or resident outcomes.
• Oversee timely electronic submission of MDS records through the CMS-designated system, review validation reports, track rejected or warning records, and ensure appropriate corrections, modifications, or follow-up are completed and retained.
• Maintain working knowledge of current CMS RAI guidance, federal long-term care requirements, applicable Indiana Department of Health and Ohio Department of Health requirements, state nursing scope-of-practice standards, and organizational policies that affect the RAI/MDS process.
• Audit MDS completion, supporting documentation, care-plan consistency, assessment timing, and identified quality or compliance risks; communicate findings and participate in corrective-action, quality assurance, performance-improvement, and survey readiness activities.
• Protect the integrity and confidentiality of resident information, maintain organized MDS and supporting records, and respond accurately and professionally to survey, audit, medical record, reimbursement, or compliance requests within assigned authority.
• Educate nurses, nurse aides, and interdisciplinary team members on MDS-related documentation, resident interviews, functional status, restorative services, skin and wound information, falls, nutrition, cognition, behaviors, and other topics that affect accurate assessment and care planning.
• Provide timely feedback when documentation does not support MDS coding or resident status, clarify expectations using current RAI guidance and organizational standards, and refer clinical practice or performance concerns to the appropriate nursing or department leader.
• Participate in orientation, in-services, competency, development, and other education related to the RAI process, documentation quality, reimbursement integrity, quality measures, and regulatory readiness.

Values and Leadership Expectations

The MDS Coordinator – RN is expected to demonstrate Heritage Pointe Communities’ values of Grace, Compassion, and Respect in interactions with residents, families, employees, providers, and colleagues.

• Grace: Approach assessment deadlines, documentation concerns, coding questions, and interdisciplinary differences with professionalism, patience, sound judgment, and a solutions-oriented mindset.
• Compassion: Keep the resident’s needs, choices, dignity, goals, and quality of life central to the assessment and care-planning process, recognizing that the MDS represents a person rather than simply a reimbursement or compliance document.
• Respect: Communicate professionally, protect confidential information, value the expertise of each discipline and address documentation or performance concerns directly and constructively.

Job Qualifications

1. Graduate of a state-approved school of professional nursing required
2. Current, active, and unrestricted Registered Nurse licensure, valid multistate privilege, or other authorization permitting RN practice in Indiana and/or Ohio, as applicable to the location and duties performed.
3. Must maintain all licensure, continuing education, competency, background, health, and other employment requirements applicable to the position and state of practice.
4. At least two years of nursing experience preferred, with long-term care, skilled nursing, rehabilitation, geriatric nursing, or senior living experience strongly preferred.
5. Previous MDS/RAI, care-planning, Medicare, PDPM, quality-measure, or reimbursement experience preferred; formal MDS education or RAC-CT certification is preferred.
6. Experience working with interdisciplinary teams, electronic health records, clinical documentation, audits, survey preparation, or staff education is preferred.

Knowledge, Skills, and Abilities

1. Working knowledge of the MDS 3.0/RAI process, Care Area Assessments, comprehensive care planning, current CMS RAI guidance, PDPM concepts, quality measures, resident rights, and documentation standards relevant to skilled nursing and long-term care.
2. Strong attention to detail, organization, analytical ability, time management, and follow-through, with the ability to manage multiple assessment deadlines and reconcile information from clinical records and interdisciplinary sources.
3. Effective verbal and written communicate skills; proficiency with electronic health records, MDS software, CMS submission systems, and standard office technology; ability to maintain confidentiality and communicate professionally with residents, families, staff, providers, auditors, and regulators.

Work Schedule and Availability

This nursing leadership and clinical coordination role is generally scheduled during business hours but requires flexibility to meet assessment deadlines, resident care needs, survey activity, month-end or reimbursement processes, and other operational requirements. Regular and reliable attendance is an essential function of the position. The MDS Coordinator – RN may occasionally be required to work beyond the regular schedule, including early mornings, evenings, weekends, or holidays, when needed to complete time-sensitive RAI/MDS responsibilities, support survey or audit activity, or maintain continuity of the assessment and care-planning process.

Physical Requirements

The physical requirements described below represent those typically required to perform the essential functions of this position. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform essential functions, unless doing so would create undue hardship or direct threat under applicable law.

• Frequently communicates, observes, reads, writes, uses a computer and clinical systems, reviews detailed resident information, and moves throughout the community; regularly alternates among sitting, standing, and walking.
• Occasionally bends, stoops, reaches, kneels, pushes or pulls equipment or supplies, and lifts or carries up to approximately 25 pounds; may assist during an emergency within training, professional scope, and safe-lifting practices.
• Works in office and resident-care settings with interruptions, noise, odors, and potential exposure to infectious agents, bodily fluids, chemicals, and other healthcare hazards; required personal protective equipment and infection-control practices must be used.

Expectations of All Employees

1. Support the organization’s mission, vision, policies, and commitment to resident-centered service.
2. Maintain confidentiality and comply with HIPAA and other privacy requirements applicable to the position.
3. Complete required education, meetings, and professional development activities.
4. Follow infection prevention, safety, emergency preparedness, and other applicable policies and procedures.
5. Demonstrate professional conduct, reliable communication, collaboration, and respect in interactions with residents, families, employees, visitors, and partners.
6. Perform other duties as assigned consistent with the position’s scope and organizational needs.

Note

This job description is intended to describe the general nature and level of work performed by employees assigned to this position. It is not intended to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, qualifications, or working conditions associated with the position. Responsibilities may be modified based on organizational and operational needs, consistent with applicable law. This job description does not constitute an employment contract or alter the at-will employment relationship. Heritage Pointe Communities reserves the right to revise this job description and to assign additional duties as appropriate.