MDS Assessment Nurse

Essential Duties and Responsibilities: 

The purpose of this position is to assess resident physical and mental function and record data on MDS forms completely and accurately; document all additional assessments required, completely and accurately; and use Care Area Assessments to determine whether to proceed or not proceed with care planning. The Assessment Nurse assists the MDS Director/Coordinators with the timely and accurate completion of both the RAI and Care Management process from admission to discharge in accordance with State and Federal guidelines and all other entities as appropriate (e.g., Minimum Data Set, discharge and re-entry tracking forms, etc.). With direction from the MDS Director/Coordinators, the Assessment Nurse may coordinate information systems operations and education for the clinical department.

• Works in collaboration with the Interdisciplinary Team to assess the needs of the resident.

• Assists with coordination and management of the daily Care Management meeting, to include review of resident care and the setting of the Assessment Reference Date.

• Complies with federal and state regulations regarding completion and coordination of the RAI process and Minimum Data Set. 

• Ensures documentation is present in the medical record to support MDS coding and care planning and CAA (Care Area Assessment).

• Maintains the frequent and accurate data entry of resident information into appropriate computerized MDS programs.

• Competes accurate coding of the MDS with information obtained via medical record review as well as observation and interview with facility staff, resident and family members for hospital and nursing home.

• Attends interdisciplinary team meetings and other meetings in order to gather information, communicate changes, and maintain and update records. 

• Continually updating knowledge base related to data entry and computer technology.

• Participate in quality assurance activities.

• Performs other duties as assigned by the MDS Director/Coordinator.

• Review Quality Measure reports for potential resident concerns and problems and implement and address these concerns in the resident care plan.

• Comply with all federal and state regulations when completing the Minimum Data Set.

• Assume responsibility for implementation of OBRA and Prospective Payment System Minimum Data Set completion schedules.

• Print Minimum Data Set documents and related reports from the software program per facility policy.

• Review reports for resident MDS assessments and care plans and take follow up action as necessary.

• Maintain confidentiality of resident and facility information.  Maintain open lines of communication between all personnel.

• Observe Resident’s Rights policies at all times. 

• Observe all facility safety policies and procedures.

• Report for work as scheduled and consistently demonstrate dependability and punctuality.

• Consistently work cooperatively with administration, nursing service personnel, physicians, community agencies, resident’s families and consultants.

• Participate in surveys by authorized government agencies.

Education and/or Work Experience Requirements: 

• RN license

• MDS experience is required

• Excellent verbal and written communication skills, including ability to effectively communicate with internal and external customers

• Excellent computer proficiency (MS Office – Word, Excel and Outlook)

• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service

• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices

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