Utilization Review MDS Coordinator

The Utilization Review MDS Coordinator coordinates, conducts, and manages the Minimum Data Set (MDS) assessment process and the Resident Assessment Instrument (RAI) cycle. This role ensures clinical documentation accurately reflects resident care needs, maintains strict compliance with state and federal regulations, and optimizes accurate reimbursement. The ideal candidate will possess sharp clinical judgment, an analytical mindset, and exceptional technical precision to oversee comprehensive MDS data reviews and successful CMS electronic submissions across several nursing facilities

Key Responsibilities

MDS Review & Quality Assurance

• MDS Data Review: Perform thorough reviews of patient charts, nursing logs, therapy logs, and electronic medical records (EMR) to ensure all clinical assessments and MDS items are coded accurately and ethically before locking data.
• Interdisciplinary Audits: Audit care plans and RAI processes continuously, correcting discrepancies across the care team to maintain strict adherence to state and federal 42 CFR 483.20 guidelines.
• Clinical Reconciliation: Collaborate with physicians, nursing staff, and therapy departments to reconcile documentation conflicts and capture precise clinical data.
• Conduct regular in person site visits and audits across assigned facilities to evaluate and reinforce RAI, MDS, and Prospective Payment System (PPS) processes working closely with the IDT team.
• Conduct weekly Zoom or Teams meeting with assigned facilities Morning Meetings, GG Meetings, MDS Meetings, Etc.
• Review validation reports and evaluates Z-Connect / Point Right prior to MDS submission

CMS Submission & Compliance

• Timely Transmission: Execute the secure, timely electronic transmission and submission of finalized MDS assessment batches to the Centers for Medicare & Medicaid Services (CMS) within federally mandated windows.
• Validation & Error Management: Monitor the CMS submission system regularly to track transmission statuses, retrieve Final Validation Reports (FVR), and rapidly resolve any rejected files, warnings, or duplicates.
• Survey Preparedness: Maintain meticulously organized, audit-ready MDS records and submission receipts to support state and federal survey teams during facility inspections.

Care Planning & Reimbursement

• Care Plan Integration: Ensure the Care Area Assessments (CAAs) trigger meaningful, individualized patient care plans based on data compiled during the MDS review.
• PDPM Optimization: Analyze clinical data to verify that the Patient-Driven Payment Model (PDPM) categories accurately match the resident’s true resource utilization and acuity level.

Reports To: Regional Clinical Reimbursement Nurse
Employment Type: Full-Time

Location: Multi-site / Regional travel required

Job Qualifications & Requirements

• License: Active, unencumbered Registered Nurse (RN) licensed in NYS.
• Experience: Minimum of 2–3 years of clinical experience in a long-term care (LTC) or skilled nursing facility (SNF), with at least 1 year of direct MDS coordination experience preferred or 1-2 years’ experience as a Utilization Review Nurse in a Hospital or Insurance setting
• Travel: Ability to travel regularly (up to 50%–75%) between regional long-term care facilities
• Technical Skills: Proficiency with long-term care electronic health records systems (e.g., PointClickCare) . Experience navigating CMS/IES electronic submission portals and CASPER reporting Preferred
• Regulatory Knowledge: Understanding of the CMS RAI Version 3.0 Manual, Medicare Part A/B guidelines, Medicaid case-mix, and PDPM mechanics.