MDS Assistant

Castle Healthcare•Anderson, IN

3d•Onsite

About The Position

The MDS Assistant is an experienced healthcare provider who ensures accurate assessment coding and current resident care plans, collaborating with or serving as the RN Coordinator. Accurate MDS coding supports reimbursement rates for covered residents and quality metrics used in public reporting. The role also ensures resident-care records are consistent with the care plan and accurately describe the care provided. The position coordinates MDS assessments, reviews clinical records and diagnosis coding, supports reimbursement and quality-measure processes, and works with the interdisciplinary team to maintain appropriate care plans and documentation. It also provides staff education, communicates care plans and progress to residents and families, and helps ensure resident needs are met.

Requirements

Current State of Indiana license as a Registered Nurse or Licensed Practical Nurse.
Ability to read, write, and speak English in an understandable manner.
Working knowledge of nursing services and administration, rehabilitation, general nursing, geriatric nursing, MDS, and its EMR application.
Good managerial, organizational, planning, computer, and interpersonal skills.
Ability to initiate or contribute to, complete, and update care plans with each MDS assessment within applicable scope of practice.
Ability to conduct in-service training of nursing staff on care plans, documentation, ADLs, and EMR application.
Ability to monitor resident EMR records for consistency and content.
Ability to identify problems and communicate them to the Director of Nursing, Social Worker, Activity Director, Diet Tech/RD, or other applicable facility staff.
Professional and cooperative manner with residents, families, and staff.
Compassion, tolerance, and understanding for elderly people.
Knowledge of ISDH standards and documentation methods in accordance with those standards.
Knowledge of and ability to navigate the Resident Assessment Instrument (RAI) Manual.
Understanding of technical and clinical criteria required for Medicare beneficiary coverage.
Physical and mental ability to perform routine job duties and cope with the mental and emotional stress of the position.
Ability to move intermittently throughout the workday and to function independently with flexibility, personal integrity, and effectiveness with residents, personnel, and support agencies.
Adequate sight and hearing, or prosthetics enabling these senses to function adequately for the role.
Must meet facility general health requirements, including a medical and physical examination.
Ability to relate to and work with ill, disabled, elderly, emotionally upset, and sometimes hostile people.
Ability to push, pull, move, or lift at least 25 pounds to a height of at least 5 feet and carry or move that weight at least 50 feet.
May need to assist with resident evacuation during emergencies.

Nice To Haves

AANAC certification preferred.

Responsibilities

Support the facility's philosophy of care and work toward its goals and objectives.
Coordinate MDS completion for initial admissions, readmissions, quarterly and annual assessments, significant changes, and as needed for PPS or insurance reimbursement.
Provide and maintain a monthly and as-needed calendar of scheduled MDS assessments, including opening assessments in the EMR for interdisciplinary team work.
Ensure each MDS section is completed on time by the appropriate department, signed in the EMR, and appropriate to the resident.
Address problems with departments' MDS sections and arrange re-education when needed, including education on accurate coding and supporting documentation.
Review ICD-10 diagnosis coding and sequencing upon admission, reentry, and each MDS completion; submit physician queries for clarification as needed.
Review clinical records daily for opportunities to capture the appropriate level of care on OBRA and PPS assessments, aligning reimbursement with care and resident characteristics; review items such as ADL Index reports, therapy projections, progress notes, and orders.
Conduct daily MDS-therapy meetings and weekly Utilization Review meetings.
Participate in pre-billing (triple-check) review of claims according to facility guidelines.
Monitor MDS-based quality measures for coding errors and improvement opportunities, and assist the interdisciplinary team in identifying measures for facility QAPI efforts.
Monitor and assist staff across departments with EMR charting, documentation, and achievement of care plan goals consistent with residents' MDS assessments.
Communicate resident care plans and progress to staff, residents, and families; set care plan review dates in PCC with MDS assessments and ensure timely signatures by applicable interdisciplinary team members.
Provide nursing staff in-service training every three months as needed on care plans and documentation.
Record, report, and follow up on documentation discrepancies or documentation that does not meet program standards.
Work with the Director of Nursing and other department heads to ensure consistency in care.
Work with or as an RN to coordinate resident care plans with physical, occupational, respiratory, and speech therapy departments when clinically appropriate.
Maintain confidentiality of resident information and respect residents' personal and property rights.
Follow fire, disaster, safety, infection-control, and evacuation policies and procedures.
Perform other duties assigned by the Administrator.
Assist with staffing coverage as needed to ensure resident needs are met.