MDS Nurse LVN

La Paloma Healthcare Center; Oceanside (CA); On-site; USD 68,000 - 82,000; Full time

Job summary

La Paloma Healthcare Center in Oceanside, CA is seeking a licensed LVN/LPN to coordinate and complete MDS assessments in compliance with CMS and state requirements. The role focuses on accurate documentation, care planning, and supporting reimbursement processes.

You will work with an interdisciplinary team to develop individualized care plans, monitor resident progress, participate in care conferences, and ensure timely MDS submissions.

Qualifications

• Current LVN/LPN license in the state of practice.
• 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.
• Proficiency in electronic health records (EHR) systems.
• Ability to work collaboratively with interdisciplinary teams.
• Must read/write/speak English clearly.

Responsibilities

• Complete MDS assessments and 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 to develop individualized care plans.
• Monitor resident progress and update care plans as needed.
• Participate in resident care conferences and quality improvement initiatives.

Skills

MDS documentation

EHR proficiency

Interdisciplinary collaboration

Organizational skills

Education

LVN/LPN license

Experience in long-term care or SNF

Tools

Microsoft Office

Job description

General Purpose

The MDS Nurse (LVN/LPN) is responsible for coordinating and completing the Minimum Data Set (MDS) assessments in compliance with federal and state regulations. This role ensures accurate documentation of resident care, supports reimbursement processes, and collaborates with interdisciplinary teams to promote quality outcomes for residents.

Essential Duties

• 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.

Supervisory Requirements

This role has no supervisory requirements.

Qualification

Education and/or Experience

• 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.
• Proficiency in electronic health records (EHR) systems.

Language Skills

Must be able to read, write, speak, and understand the English language. Ability to read technical procedures. Ability to read and comprehend policy and procedure manuals. Ability to effectively present information and respond to questions from managers and employees. Must be able to relate information concerning a resident's condition.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates, Licenses, Registrations

To perform this job successfully, an individual must be proficient in the Microsoft Suite products. Must maintain all required continuing education/licensing. Must remain in good standing with the State Board of Nursing at all times.

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 accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must occasionally lift and/or move up to 25 pounds. Prolonged use of a desktop or laptop computer. While performing the duties of this job, the employee is regularly required to sit, stand, walk, and talk, read or hear. Frequent use of all office-related equipment to include; copier/scanner/fax, telephone, and calculator. Travel by auto or airline may be required.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations 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.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.