Regional MDS Resource

Pacificare Health Management; Los Angeles (CA); On-site; USD 90,000 - 140,000; Full time

Job summary

Pacificare Health Management seeks a Regional MDS Resource to provide clinical and regulatory oversight of the MDS process across multiple SNFs. You will mentor MDS Coordinators, Directors of Nursing, and interdisciplinary teams while supporting regulatory compliance and reimbursement optimization.

The role requires CA RN/LVN licensure, 3+ years MDS experience in SNFs, and 2+ years multi-facility/regional clinical experience. Travel across the LA/surrounding regions is expected.

Qualifications

• > Active California RN or LVN license in good standing.
• > Minimum of 3 years MDS experience in a Skilled Nursing Facility.
• > Minimum of 2 years multi-facility/regional clinical experience preferred.
• > Extensive knowledge of MDS 3.0, RAI Manual, PDPM reimbursement, care planning, QM and Five-Star, CMS/CA SNF regulations.
• > Strong clinical assessment and auditing skills.
• > Excellent communication, organizational, and leadership abilities.
• > Proficiency with electronic health records and MDS software systems.
• > Ability to travel regularly within LA County, Santa Barbara, Contra Costa and surrounding regions.

Responsibilities

• Provide oversight and support for MDS operations at multiple SNFs.
• Monitor MDS submissions and ensure CMS/state compliance.
• Conduct routine audits of MDS assessments, care plans, and clinical records.
• Analyze PDPM reimbursement and identify optimization opportunities.
• Monitor QRP metrics, prepare performance improvement plans.
• Assist with ADRs, TPE reviews, audits, and payer documentation.
• Coordinate collection/review/submission of medical records.
• Guide documentation standards and Medicare/Regulatory requirements.
• Track ADR outcomes, denial trends, and appeal opportunities.
• Develop training programs on MDS accuracy, QRP, and ADR readiness.
• Educate and mentor MDS staff and interdisciplinary teams.
• Engage facility leadership to identify clinical/operational improvements.
• Conduct onsite visits and remote reviews as needed.
• Stay current with CMS regs, RAI updates, and PDPM requirements.
• Participate in corporate clinical meetings and report performance.
• Implement AI tools for documentation review and reimbursement analytics.

Skills

CA RN/LVN license

MDS experience

Regional/Multi-facility exp

MDS 3.0 knowledge

PDPM knowledge

CMS regulations knowledge

Auditing skills

Leadership

EHR proficiency

Tools

MDS software

EHR systems

Job description

POSITION TITLE

The RAI/MDS policy will provide the scope of the MDS Nurse Coordinator position for the facility.

Occupational Exposure: Category I

Department: Nursing

Reports to: VP of Clinical Services

FLSA: Non- exempt

POSITION SUMMARY

The Regional MDS Resource provides clinical and regulatory oversight of the Minimum Data Set (MDS) process across multiple Skilled Nursing Facilities (SNFs). This role ensures accurate and timely completion of MDS assessments, care planning, Medicare and Medicaid reimbursement optimization, quality measure performance, and regulatory compliance. The Regional MDS Resource serves as a resource and mentor to facility MDS Coordinators, Directors of Nursing, and interdisciplinary teams while supporting operational and financial outcomes throughout the organization.

POSITION RELATIONSHIP

Collaborates with all MDS Coordinators in the facilities, physicians and facility leadership and other department employees as the Regional MDS Resource coordinates resident assessment instrument implementation. Provides resident assessment related education.

QUALIFICATIONS

1. PROFESSIONAL

• Active California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license in good standing.
• Minimum of 3 years of MDS experience in a Skilled Nursing Facility.
• Minimum of 2 years of multi-facility, consulting, or regional clinical experience preferred.
• Extensive knowledge of:
  • MDS 3.0
  • RAI Manual
  • PDPM reimbursement methodology
  • Care planning processes
  • Quality Measures and Five-Star Program
  • CMS and California SNF regulations
• Strong clinical assessment and auditing skills.
• Excellent communication, organizational, and leadership abilities.
• Proficiency with electronic health records and MDS software systems.
• Ability to travel regularly throughout the Los Angeles County, Santa Barbara County, Contra Costa County and surrounding regions.

Preferred

• RAC-CT Certification.
• Previous experience as MDS Coordinator, Regional MDS Consultant, or Regional Clinical Consultant.
• Experience supporting multiple facilities within a post-acute care organization.

2. POSITION RESPONSIBILITIES

• a. Provide oversight and support for MDS operations at multiple SNFs.
• b. Monitor MDS submission processes and ensure compliance with CMS and state requirements.
• c. Conduct routine audits of MDS assessments, care plans, CAA documentation, and supporting clinical records.
• d. Analyze reimbursement outcomes under PDPM and identify opportunities for optimization while maintaining compliance.
• e. Monitor facility performance related to the Skilled Nursing Facility Quality Reporting Program (SNF QRP), including review of quality measure data, compliance requirements, reporting deadlines, and opportunities for performance improvement.
• f. Analyze QRP metrics and trends, collaborate with facility leadership to develop action plans, and provide education to improve quality outcomes and reduce the risk of payment penalties.
• g. Assist facilities with Additional Documentation Requests (ADRs), Targeted Probe & Educate (TPE) reviews, Medicare audits, and other payer documentation reviews.
• h. Coordinate the collection, review, and submission of medical records and supporting documentation in response to ADRs and audit requests.
• i. Provide guidance to facility teams regarding documentation standards, medical necessity requirements, and strategies to reduce claim denials while maintaining regulatory compliance.
• j. Track ADR outcomes, denial trends, and appeal opportunities, and recommend corrective actions to improve facility performance and reimbursement outcomes.
• k. Develop and implement educational programs related to MDS accuracy, QRP compliance, PDPM optimization, ADR preparedness, and regulatory requirements.
• l. Track and monitor Quality Measures (QMs), Five-Star ratings, and facility performance metrics.
• m. Educate and mentor MDS Coordinators, DONs, and interdisciplinary teams regarding MDS regulations, coding guidelines, and best practices.
• n. Collaborate with facility leadership to identify areas of clinical and operational improvement.
• o. Conduct onsite facility visits and remote reviews as needed.
• p. Maintain current knowledge of CMS regulations, RAI Manual updates, PDPM requirements, and California-specific regulations.
• q. Participate in corporate clinical meetings and provide regular performance reports to leadership.
• r. Implement and monitor the effectiveness of AI software tools, documentation review, assessment support, and reimbursement analytics tools, ensuring compliance with CMS, HIPAA, and organizational standards.
• s. Perform other related duties as required or assigned.