Medicare PCR Specialist - Claims & Compliance

Oasis Health Partners; Miami (FL); On-site; USD 60,000 - 78,000; Full time

Job summary

Oasis Health Partners is seeking a PCR Specialist to organize and submit pre-claim review requests to Palmetto GBA under CMS RCD for Medicare home health reimbursement. You will ensure complete documentation, coordinate with clinical staff and physicians, and monitor submission status to reduce non-affirmations and ADRs.

You will validate documents, manage PDGM and OASIS alignment, and maintain strict HIPAA compliance while supporting process improvements to reach a high first-pass affirmation

Qualifications

• High school graduate; prefer Associate’s or Bachelor’s in HIM/Healthcare Admin or related field.
• Minimum two years in healthcare billing, medical records, or revenue cycle, preferably Medicare home health.
• Knowledge of Medicare home health regs (PDGM, OASIS, HHP Participation, CMS-485, Face-to-Face).
• Familiarity with RCD program and Palmetto GBA iDex/eServices portal preferred.
• Experience with home health EMR system (Kinnser/WellSky) and MS Office.

Responsibilities

• Retrieve patient documentation from EMR and source systems.
• Assemble full PCR documentation packet for each 60-day period.
• Validate PCR paperwork against checklist before submission.
• Submit PCR requests via Palmetto GBA iDex/eServices portal.
• Identify deficiencies and coordinate with clinicians to obtain missing docs.
• Verify demographics, Medicare ID, HCPCS, and alignment with OASIS and claims.
• Record submissions in PCR Tracker with status and dates.
• Analyze non-affirmation codes and decide on resubmission or appeal.
• Prepare and submit non-affirmed resubmissions and redeterminations.
• Communicate outcomes to billing, clinical, and management teams.
• Provide regular PCR volume and performance reports.
• Participate in process improvements to achieve 90% first-pass rate.
• Stay updated on CMS, Palmetto GBA, and RCD changes; complete HIPAA training.

Skills

MS Office Suite proficiency

Kinnser/WellSky experience

Effective documentation drafting

Interdepartmental communication

HIPAA compliance

Education

Health Information Management or Healthcare Administration related degree

Tools

Kinnser/WellSky

Microsoft Office (Excel, Word, Outlook)

Job description

Oasis Health Partners is seeking a PCR Specialist to organize and submit pre-claim review requests to Palmetto GBA under CMS RCD for Medicare home health reimbursement. You will ensure complete documentation, coordinate with clinical staff and physicians, and monitor submission status to reduce non-affirmations and ADRs.

You will validate documents, manage PDGM and OASIS alignment, and maintain strict HIPAA compliance while supporting process improvements to reach a high first-pass affirmation