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The MDS Nurse is an experienced health care provider who ensures accurate assessment coding and up-to-date care plans for all residents, in collaboration with, or as, the RN Coordinator. Additionally, the MDS nurse, through accurate assessment coding, establishes reimbursement rates for covered residents and quality metrics used for public reporting. The MDS Nurse also ensures records pertaining to resident care are consistent with the plan of care and are descriptive of the care rendered.

1. 1. Must be physically and mentally capable of performing routine job duties.
2. 2. Must have working knowledge of nursing services, nursing administration, rehabilitation, general nursing, geriatric nursing, the MDS, and its computer application (EMR).
3. 3. Must have good managerial, organizational, planning, computer, and interpersonal skills.
4. 4. Ability to initiate or provide input, complete, and update care plans with each MDS assessment completion and within applicable scope of practice.
5. 5. Ability to conduct in-service training of nursing staff on care plans, documentation, ADLs, and EMR application.
6. 6. Ability to monitor resident EMR records for consistency and content.
7. 7. Ability to identify problems and to communicate those problems to the Director of Nursing, Social Worker, Activity Director, Diet Tech/RD, or other facility staff as applicable to the department effected.
8. 8. Be personable with residents, families, and staff in a professional and cooperative manner.
9. 9. Must have compassion, tolerance, and understanding for the elderly.
10. 10. Knowledge of ISDH standards and methods of documentation in accordance with those standards.
11. 11. Must possess knowledge and be able to effectively navigate the Resident Assessment Instrument (RAI) Manual.
12. 12. Must possess understanding of technical and clinical criteria required to cover Medicare beneficiaries.

1. A. Support the facility's philosophy of care and strive to achieve its goals and objectives.
2. B. Coordinate the completion of the MDS upon:
   1. a. initial admission
   2. b. readmission
   3. c. quarterly
   4. d. annually
   5. e. the occurrence of a significant change
   6. f. and as needed for PPS/Insurance Reimbursement
3. C. Provide calendar monthly and as needed of scheduled MDS assessments. Opening MDS assessments in the EMR, allowing the IDT to work from the In-Progress list, also satisfies this requirement.
4. D. Assure the timely completion of each section of the MDS by proper department, signing of the form by staff on EMR, and its resident appropriateness.
5. E. Confer with each department regarding any problems that occur in its sections of the MDS and arrange for re-education when necessary. Including, but not limited to, accurate coding and supportive documentation.
6. F. Review ICD 10 diagnosis coding and sequencing upon admission, reentry, and with each MDS assessment completion and complete Physician Query for clarification as needed.
7. G. Complete daily review of clinical records for opportunities to capture highest level of care on OBRA and PPS assessments, aligning reimbursement with care and resident characteristics. This includes but is not limited to a review of the ADL Index Report, Therapy projections, progress notes, and orders.
8. H. Conduct daily MDS-therapy meeting and weekly Utilization Review meeting.
9. I. Participate in pre-billing (triple check) review of claims per facility guideline.
10. J. Monitor MDS-based Quality Measures for coding errors, opportunities to resolve when applicable, and assist IDT in identifying measures to include in facility QAPI efforts.
11. K. Monitor and assist staff in all departments regarding EMR charting, documentation and achieving Care Plan goals in accordance with the resident’s MDS.
12. L. Communicate resident care plan and progress to staff, resident and family. Ensure care plan review dates are set in PCC with MDS assessments and reviews are signed timely by each applicable IDT member.
13. M. Conduct in-service training of nursing staff every three months as needed on care plans and documentation.
14. N. Record, report and follow up on discrepancies in documentation which are not consistent and/or do not meet program standards.
15. O. Work closely with the Director of Nursing and other department heads to ensure consistency in care.
16. P. Work with, or as, RN to coordinate resident Care Plan with physical, occupational, respiratory, and speech therapy department to ensure proper care and treatment when clinically appropriate.
17. Q. Maintain the confidentiality of resident information and honor his/her personal and property rights.
18. R. Follow established fire, disaster, safety, infection control and evacuation policies and procedures.
19. S. Perform other duties as assigned by Administrator.
20. T. Assist with staffing coverage as needed to ensure resident needs are met.

1. 1. A current State of Indiana license as a Registered Nurse or Licensed Practical Nurse.
2. 2. Must be able to read, write, and speak English in an understandable manner.
3. 3. AANAC certification preferred.

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English Language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at time hostile people in the facility.
• Must be able to push, pull, move and / or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move and / or carry such weight a minimum distance of 50 feet.
• May be necessary to assist in the evacuation of residents during emergency situations.

• Works in office areas as well as areas throughout the facility
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies / personnel, etc., under all conditions and circumstances.
• May be exposed to heat/cold temperatures in kitchen/storage areas.
• May be subject to sudden temperature changes when entering refrigerator/freezer.
• Communications with the medical staff, nursing personnel, and other department directors
• Works beyond normal duty hours, on weekends and holidays when necessary.
• Is subject to call back during emergency conditions (severe weather, evacuation, post-disaster, etc.)
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminates.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses

May be subject to the handling of and exposure to hazardous chemicals