MDS Case Manager (Long-Term Care)

Job Summary

The MDS Case Manager oversees the resident assessment and care planning process to ensure accurate, timely completion of the Minimum Data Set (MDS) and related regulatory documentation. This role evaluates residents, gathers assessment data, completes Care Area Assessments (CAA's), and develops resident-centered care plans in collaboration with the interdisciplinary team. The MDS Case Manager plays a key role in maintaining compliance, supporting quality outcomes, and ensuring each resident's needs, preferences, and risks are appropriately identified, communicated, and addressed.

General Responsibilities

• Evaluate residents, gather required data, and complete Minimum Data Set (MDS) assessments in accordance with regulatory requirements.
• Complete Care Area Assessments (CAA's) and resident-centered care plans for assigned residents.
• Complete required assessment documentation, including elopement risk, Braden Scale, fall risk, pain assessment, PHQ-9, cognitive assessment, and related clinical assessments as applicable.
• Perform chart and resident audits during the assessment process, including review of weight management status, hydration status, lab results, pharmacy recommendations, physician orders, and dietary orders.
• Update care plans at least weekly, or more frequently as indicated, in accordance with physician orders and resident needs.
• Remain actively involved in the MDS transmission process until an accepted validation report is received for each submitted MDS.
• Manage the monthly MDS assessment schedule and notify each neighborhood of resident dates and applicable "look back period" timelines.
• Communicate thoroughly with neighborhood charge nurses and other team members regarding assessment findings, scheduling, and care planning needs.
• Actively participate in weekly interdisciplinary team (IDT) meetings for assigned residents.
• Participate in scheduled care plan meetings with families and communicate resident status and care plan updates.
• Consult with physicians, family members, dietary services, social services, life enrichment, and nursing staff to maintain current, relevant care plans.
• Update pocket care plans for direct care staff to reflect each resident's current preferences and needs.
• Maintain professional conduct at all times, including professional attire, respectful communication, and appropriate handling of issues with staff, residents, and families.
• Oversee the care process for assigned residents and take immediate responsibility to address identified issues with the appropriate staff.
• Communicate regularly with supervisor regarding requested time off, sick days, and weather-related delays.
• Perform other duties as assigned to support quality care, regulatory compliance, and interdisciplinary coordination.

Qualifications

• Current Oklahoma nursing license (LPN or RN) required.
• Minimum of two years of long-term care experience required.
• Ability to read, write, and speak English.
• Strong assessment, documentation, and organizational skills.
• Ability to collaborate effectively with interdisciplinary teams, residents, and families.
• Working knowledge of MDS processes, care planning, and long-term care regulations preferred.

Physical Working Conditions

• Regular exposure to body fluids, infection, odors, and resident behaviors.
• Exposure to chemical and cleaning solutions.
• Must possess adequate sight and hearing, with or without assistive devices, to meet job requirements.
• Regularly required to stand, walk, use hands, reach, talk, and hear.
• Occasionally required to sit, climb, balance, stoop, kneel, crouch, crawl, taste, or smell.
• Must regularly lift up to 10 pounds, frequently lift up to 25 pounds, and occasionally lift up to 50 pounds.
• Vision requirements include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

The work environment characteristics described are representative of those encountered while performing essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

Benefits

• 403B Retirement savings plan
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid sick time
• Paid personal time off
• Referral bonus program
• Tuition reimbursement
• Vision insurance