MDS Documentation Specialist

5 days ago


Silver Spring, Maryland, United States Regency Care of Silver Spring Full time
Job Summary

The MDS Documentation Specialist at Regency Care of Silver Spring will be responsible for coordinating and maintaining accurate and compliant Minimum Data Set (MDS) documentation for all residents in our healthcare facility. This role requires a deep understanding of state and federal regulations as they pertain to MDS and precise record-keeping.

Key Responsibilities
  • Conduct thorough resident assessments to accurately capture their medical and social needs, ensuring comprehensive and up-to-date documentation.
  • Collaborate with the interdisciplinary team to ensure accurate and timely documentation of patient information, maintaining seamless communication and coordination.
  • Review and modify MDS documentation as needed to reflect changes in patient status and progress, adhering to state and federal regulations.
  • Monitor and ensure accuracy of MDS and care plans, identifying and addressing any discrepancies or inconsistencies.
  • Provide training and education to staff on proper MDS coding and documentation guidelines, promoting best practices and compliance.
  • Communicate effectively with families and caregivers to gather information and update them on resident progress, fostering strong relationships and trust.
  • Participate in facility meetings and committees related to MDS documentation and compliance, contributing to the development of policies and procedures.
  • Stay up-to-date with changes in MDS regulations and implement necessary changes in documentation procedures, ensuring ongoing compliance and accuracy.
Requirements
  • Active Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of Maryland.
  • Minimum of 2 years of experience working as an MDS Coordinator in a long-term care facility.
  • In-depth understanding of MDS documentation requirements and state/federal regulations.
  • Strong attention to detail and accuracy in record-keeping, with a focus on precision and compliance.
  • Excellent communication and interpersonal skills, with the ability to work effectively with diverse stakeholders.
  • Ability to work independently and as part of a team, with a strong sense of accountability and responsibility.
  • Proficient in computer skills and electronic medical record systems, with a working knowledge of PointClickCare software.


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