MDS LVN: Care Planning & Documentation Specialist

Del Rosa Villa in; San Bernardino (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Del Rosa Villa in is seeking an LVN/LPN to coordinate and complete MDS assessments in compliance with federal and state regulations, ensuring accurate documentation and supporting reimbursement. You will collaborate with interdisciplinary teams to develop individualized care plans, monitor resident progress, and participate in care conferences.

The role emphasizes staying current with CMS requirements and contributing to quality improvement initiatives.

Qualifications

• Current LVN/LPN license in the state of practice.
• Prior experience in long‑term care or skilled nursing facility preferred.
• Knowledge of MDS 3.0, RAI process, and Medicare/Medicaid reimbursement guidelines.
• Strong organizational skills with attention to detail and accuracy.
• Ability to work collaboratively with interdisciplinary teams.

Responsibilities

• Complete MDS assessments and care area assessments (CAAs) within required timelines.
• Ensure accuracy of resident clinical documentation to support care planning and reimbursement.
• Maintain compliance with CMS, state, and facility guidelines.
• Collaborate with interdisciplinary team members to develop individualized care plans.
• Monitor resident progress and update care plans as needed.
• Participate in resident care conferences and quality improvement initiatives.
• Ensure MDS submissions meet regulatory requirements for Medicare/Medicaid reimbursement.
• Assist with audits and surveys by providing accurate documentation and reports.
• Stay current with regulatory changes impacting MDS and skilled nursing documentation.
• Work closely with nursing staff, therapy, social services, and dietary teams to gather resident information.
• Provide education and guidance to staff on documentation standards and MDS requirements.
• Communicate effectively with residents and families regarding care planning.

Skills

Documentation

Regulatory compliance

EHR systems

Interdisciplinary collaboration

English proficiency

Education

LVN/LPN license

Long-term care experience

Tools

Microsoft Office Suite

Job description

Del Rosa Villa in is seeking an LVN/LPN to coordinate and complete MDS assessments in compliance with federal and state regulations, ensuring accurate documentation and supporting reimbursement. You will collaborate with interdisciplinary teams to develop individualized care plans, monitor resident progress, and participate in care conferences.

The role emphasizes staying current with CMS requirements and contributing to quality improvement initiatives.