Medical Coding Assistant Jobs in Bozeman, MT (NOW HIRING)

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).

This position reports to the Rest Home Administrator and does not supervise other employees.

Each duty listed below makes up at least 20% of the job. All other functions are included in "Other Duties as Assigned." All listed duties are considered essential unless otherwise indicated.

• 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.
• Assist with 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. Duties may include special projects, assist other employees, and participate in ongoing training. In the event of a declared emergency (e.g., fire, flood, riot, or other disaster), County employees may be required to provide services during the emergency and subsequent recovery period.

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.

Skill in:

• 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.

Ability to:

• Work independently while maintaining compliance with established procedures.
• Prioritize tasks and manage multiple assessments simultaneously.
• Exercise sound clinical judgment and attention to detail.
• Communicate effectively, both verbally and in writing, with diverse audiences.
• Maintain confidentiality and demonstrate professionalism in all interactions.

• 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; and
• 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.

As a condition of hire, pre-employment drug testing and background investigation may be done.

NOTE: Must be willing to work in a smoke free campus.

To be considered for this position please be prepared to attach the following required documents: Cover Letter, Resume, 3 Work References

Gallatin County is an equal opportunity employer. All applicants will be considered for employment on the basis of merit and qualifications without regard to race, creed, religion, color, or national origin or because of age, physical or mental disability, marital status, or sex when the reasonable demands of the position do not require an age, physical or mental disability, marital status, or sex distinction.