PCR Specialist

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

Job Highlights

The Pre-Claim Review (PCR) Specialist organizes, prepares, and submits pre-claim review requests to Palmetto GBA under the CMS Review Choice Demonstration (RCD) program in order to achieve claim affirmation for Medicare home health reimbursement. He/she functions under the direction, instruction, and supervision of the Pre-Bill Supervisor / Billing Manager and the Director of Nursing and/or appropriate supervisor. The PCR Specialist reviews each patient case prior to and after PCR submission to ensure all required documentation components are present and coordinates with clinical, intake, and physician practice partners to resolve any concerns that could lead to non-affirmation, claim rejection, or Additional Documentation Requests (ADRs).

Qualifications

• High school graduate; prefer Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field
• Minimum two (2) years of experience in healthcare billing, medical records, or revenue cycle, preferably in a Medicare-certified home health agency
• Working knowledge of Medicare home health regulations including PDGM, OASIS, the Home Health Conditions of Participation, CMS-485 Plan of Care, and Face-to-Face encounter requirements
• Working knowledge of the Review Choice Demonstration (RCD) program and PCR submission workflow through Palmetto GBA’s iDex/eServices provider portal preferred
• Hands-on experience with at least one home health EMR system: Kinnser/WellSky
• Proficiency in Microsoft Office Suite, particularly Excel, Word, and Outlook
• Ability to read and write consistent with job requirements, including the ability to draft professional documentation requests to physicians, hospitals, and skilled nursing facilities
• Ability to establish and maintain a good work relationship with clinical staff, intake personnel, physician practices, and the personnel of the Agency
• Strong attention to detail and ability to meet deadlines, including a three (3) business-day submission turnaround from receipt of complete source documentation
• Ability to maintain strict confidentiality of patient and Agency information consistent with HIPAA requirements
• Bilingual English/Spanish preferred
• Coding or billing certification preferred (CCS, CCA, CPC, CBCS, or equivalent)

Responsibilities

• Retrieves patient documentation from the Agency’s EMR and supporting source systems, including physician EMRs, hospital HIM departments, and SNF records
• Assembles the complete PCR documentation packet for each 60-day billing period, including CMS-485 Plan of Care, OASIS assessment, Face-to-Face encounter documentation, physician orders, skilled visit notes, and physician certification
• Performs pre-submission validation against the Agency’s PCR checklist to confirm all required elements are present, signed, dated, and within applicable date windows
• Submits PCR requests electronically through Palmetto GBA’s iDex/eServices provider portal, batching both consecutive 30-day billing periods within a 60-day certification cycle when orders cover the full care period
• Identifies documentation deficiencies prior to submission and coordinates with the appropriate clinical staff, intake coordinators, physicians, or external partners to obtain corrected or missing documents
• Verifies accuracy of patient demographics, Medicare ID (MBI), HCPCS coding on the PCR cover sheet, and alignment between the OASIS, Plan of Care, and billing claim
• Records and tracks each submission in the Agency’s PCR Tracker, including submission date, status, Unique Tracking Number (UTN), affirmation decision, and decision date
• Analyzes non-affirmation reason codes (e.g., 5FF2F) and determines whether to pursue a corrected resubmission or a redetermination-level appeal
• Prepares and submits non-affirmed PCR resubmissions and redetermination appeals, including supporting argument letters, CMS regulatory citations, and any newly obtained documentation
• Communicates affirmation outcomes (affirmed, partially affirmed, or non-affirmed) to billing, clinical, and management stakeholders in a timely manner
• Provides regular reports to the Pre-Bill Supervisor on PCR volume, affirmation rate, common deficiencies, and recommended process improvements
• Participates in process-improvement initiatives aimed at achieving and sustaining a first-pass affirmation rate of 90% or higher
• Stays current on CMS, Palmetto GBA, and RCD program updates, including changes to LCDs, Medicare home health Conditions of Participation, PDGM billing rules, and the iDex/eServices portal
• Completes required HIPAA training and complies with all Agency privacy and security policies; accesses only the minimum PHI necessary to perform the duties of the position
• Performs other related duties as assigned by the Pre-Bill Supervisor or Director of Nursing

Functional Abilities

• Able to communicate verbally and in writing to the extent required by the position
• Able to physically perform the duties required by the position