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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