Nursing-MDS Care Plan Coordinator LPN/RN

Overview
Join our dynamic healthcare team as a MDS Care Plan Nurse, where you will play a vital role in coordinating comprehensive patient care plans within a skilled nursing facility. This position offers an exciting opportunity to utilize your clinical expertise and passion for patient-centered care to improve outcomes and ensure compliance with regulatory standards. As a key member of the interdisciplinary team, you will lead the development and review of Minimum Data Set (MDS) assessments, ensuring accurate documentation and effective care planning that aligns with Medicare and Medicaid requirements. Your energetic approach and attention to detail will drive quality improvements and support optimal patient recovery pathways.

Responsibilities

• Conduct thorough MDS assessments to evaluate patient needs, functional status, and clinical conditions across various care settings, including inpatient, outpatient, and home care environments.
• Collaborate with interdisciplinary teams—including nursing staff, physicians, social workers, and therapists—to develop individualized care plans that meet regulatory standards such as NCQA and CMS guidelines.
• Review medical records, clinical documentation, and coding (ICD-10/ICD-9/CPT) to ensure accuracy, completeness, and compliance with HIPAA regulations.
• Lead discharge planning efforts by coordinating post-acute services like hospice care or home health to facilitate seamless transitions for patients.
• Utilize EMR systems such as Cerner, Epic, Athenahealth, eClinicalWorks, or other EHR platforms to document assessments, interventions, and progress notes efficiently.
• Perform utilization review and management activities to optimize resource utilization while maintaining high-quality patient care.
• Stay current with industry standards related to Medicare/Medicaid reimbursement models like DRG (Diagnosis Related Group) classifications and ensure documentation aligns accordingly.
• Oversee and monitor fall program.
• On call rotation with DON/ADON.

Requirements

• Valid nursing license with current registration in the state of practice.
• Proven experience in managed care settings with a strong understanding of Medicare/Medicaid regulations and NCQA standards.
• Demonstrated proficiency in medical coding (ICD-10/ICD-9), CPT coding, and clinical documentation improvement initiatives.
• Familiarity with EMR/EHR systems for documentation review and data management.
• Knowledge of physiology, anatomy, medical terminology, and healthcare regulations including HIPAA compliance.
• Experience in inpatient or outpatient settings—particularly within nursing homes, rehabilitation facilities, or hospice environments—is preferred.
• Strong case management skills with an emphasis on discharge planning and utilization management processes.
• Excellent communication skills to effectively collaborate across multidisciplinary teams while maintaining meticulous medical records. Join us in making a difference by ensuring high-quality patient care through precise assessment and innovative care planning! We are committed to supporting your professional growth while fostering a vibrant work environment dedicated to excellence in healthcare delivery.

Pay: From $40.00 per hour

Benefits:

• Dental insurance
• Disability insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Retirement plan
• Vision insurance

License/Certification:

• LPN or RN (Required)

Work Location: In person