PCR Specialist

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