Director of Minimum Data Set (MDS) - RN

General Purpose 

The Director of Minimum Data Set (MDS) provides administrative and clinical oversight to the MDS Coordinator in the completion, accuracy, and timely submission of MDS assessments in compliance with federal and state regulations. This role assists the interdisciplinary team with data collection, documentation, and care planning activities to promote high-quality, resident-centered care. The MDS Assistant plays a key role in supporting regulatory compliance, reimbursement accuracy, and overall clinical operations within the long-term care setting.

Responsibilities

Regulatory Compliance Support

·       Assist the MDS Coordinator in ensuring facility compliance with federal and state regulations related to MDS assessments, care planning, and documentation.

·       Help monitor assessment reference dates, tracking schedules, and submission deadlines to support timely completion.

·       Assist with preparation activities related to survey readiness and documentation review.

MDS Data Collection & Documentation

·       Gather and compile clinical information from medical records, nursing notes, therapy documentation, and other sources to support accurate MDS completion.

·       Assist with coding of MDS sections under the direction and review of the MDS Coordinator.

·       Maintain organized and complete supporting documentation for MDS assessments and care plans.

·       Ensure accuracy and consistency of data entered into the electronic health record (EHR) and MDS software.

Interdisciplinary Collaboration

·       Collaborate with nursing staff, therapy, dietary, social services, and other departments to gather information needed for comprehensive MDS assessments.

·       Participate in interdisciplinary care planning meetings as directed.

·       Communicate effectively with the MDS Coordinator regarding resident status changes, assessment timelines, and documentation needs.

Reimbursement Support

·       Support the MDS Coordinator in accurate MDS coding and documentation to promote appropriate Medicare and Medicaid reimbursement.

·       Assist with tracking of assessment schedules to prevent missed or late assessments that may impact reimbursement.

·       Alert the MDS Coordinator to potential documentation gaps or discrepancies that could affect case-mix classification.

Quality & Process Support

·       Assist with internal audits of MDS assessments and supporting documentation as directed.

·       Support the implementation of corrective action plans and process improvements identified by the MDS Coordinator or facility leadership.

·       Maintain knowledge of MDS processes, assessment timelines, and documentation standards through ongoing education and training.

Qualifications

·       High school diploma or GED required; associate or bachelor’s degree in a healthcare-related field preferred.

·       Registered Nurse (RN) licensure preferred, or equivalent clinical experience.

·       Minimum of 1–2 years of experience in a long-term care or skilled nursing facility setting preferred.

·       Basic familiarity with MDS assessments, RAI processes, and care planning preferred; willingness to learn required.

·       Working knowledge of federal and state regulations related to long-term care documentation and compliance.

·       Strong organizational skills with attention to detail and accuracy in documentation.

·       Effective written and verbal communication skills with the ability to work collaboratively with interdisciplinary teams.

·       Proficiency with electronic health records (EHR) and basic computer applications; experience with MDS software a plus.

·       Ability to manage multiple tasks, meet deadlines, and maintain confidentiality in a compliance-driven environment.

·       Regular and reliable attendance is required to perform the essential functions of this position. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. 

·       Ability to sit, stand, and use a computer for extended periods.

·       Visual and auditory acuity sufficient to review clinical documentation and communicate with staff and residents.

·       Ability to meet deadlines and manage multiple tasks simultaneously.

·       Must be able to lift up to 25 pounds at a time.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

·      The noise level in the work environment is usually low to moderate.

·      Fast-paced setting that requires responsiveness to time-sensitive assessment deadlines and regulatory requirements.

·      Collaborative environment with frequent coordination across departments (nursing, therapy, billing, social services, and administration).

·      Structured and compliance-driven workplace with strict adherence to healthcare regulations, confidentiality (e.g., HIPAA), and documentation standards.

·      Requires adaptability and professionalism when handling sensitive situations involving residents, families, and care staff

Disclaimer

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.