The MDS Assessor is responsible for conducting assessments of patients' physical, mental, and functional health using the Minimum Data Set (MDS) tool. This role involves gathering, documenting, and analyzing patient information to create care plans that meet regulatory standards and ensure optimal care delivery. The MDS Assessor works closely with healthcare providers, administrative teams, and regulatory agencies to ensure compliance with state and federal guidelines.

Key Responsibilities:

Patient Assessments:
- Complete initial, quarterly, and annual MDS assessments for all patients in compliance with regulatory standards (e.g., CMS, state agencies).
- Review and update the MDS as needed based on changes in the patient's condition, ensuring accuracy in documenting health status, functional abilities, and cognitive functioning.
- Conduct interviews with patients and family members to gather relevant health data.
Care Plan Development:
- Collaborate with interdisciplinary teams, including physicians, nurses, social workers, and therapists, to develop individualized care plans based on the MDS assessment results.
- Ensure care plans reflect the patient's needs, preferences, and goals, and that they align with MDS data.
Regulatory Compliance:
- Ensure all MDS documentation complies with state and federal regulations and is up-to-date.
- Maintain a working knowledge of MDS-related policies, including updates and changes to CMS regulations.
- Work with the facility’s quality assurance teams to ensure documentation is in line with healthcare regulations.
Billing and Reimbursement:
- Use MDS assessment data to assist in proper billing and reimbursement processes.
- Ensure that MDS data supports accurate coding for reimbursement under Medicaid, Medicare, and other insurance programs.
Quality Assurance and Reporting:
- Assist in quality assurance initiatives by identifying trends and areas for improvement based on MDS assessment results.
- Provide reports and analysis to management regarding the quality of patient care and MDS documentation.
Communication:
- Communicate effectively with medical, nursing, and administrative staff regarding MDS findings and care plan adjustments.
- Act as a resource to staff members on MDS-related issues, including assessment procedures and regulatory compliance.
Training and Education:
- Stay current on MDS-related changes in regulations, software, and best practices.
- Participate in training and professional development to improve MDS assessment accuracy and understanding.
- Provide training to new staff and assist in educating other team members about MDS assessment processes and regulatory requirements.

Qualifications:

Education:
- Bachelor’s degree in Nursing (RN preferred) or related healthcare field (e.g., Social Work, Health Administration).
- MDS Certification (or willingness to obtain certification).
Experience:
- Previous experience in long-term care or healthcare settings is preferred.
- Experience completing MDS assessments and care planning processes is highly desirable.
- Knowledge of Medicare, Medicaid, and insurance billing processes is an asset.
Skills:
- Strong understanding of MDS assessments, care planning, and regulatory compliance.
- Excellent communication and interpersonal skills.
- Proficiency in using MDS software and healthcare management systems.
- Attention to detail, critical thinking, and problem-solving abilities.
Certifications/Licenses:
- Registered Nurse (RN) license preferred.
- MDS certification (or willingness to pursue).

Work Environment:

This role typically works within a healthcare facility, such as a nursing home or assisted living facility, where patient assessments are conducted.
The work environment may involve regular interactions with patients, family members, and various healthcare professionals.

Key Competencies:

Knowledge of federal and state regulations regarding patient care in long-term care.
Ability to accurately assess and document patient health status.
Attention to regulatory deadlines and adherence to healthcare standards.
Strong organizational and time management skills.

Verrazano Nursing and Post-Acute Center

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MDS Assessor