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Patient Care Coordinator - LPN

Job Description | Triton Health Systems, LLC.


Date Prepared: 6/2/2010 12:00:00 AM Reports To: Supervisor of Patient Care Coordination
Manager Approval: Department: Medical Management
HR Review: Status: Non-exempt
Employee Signature: Revisions:
Job Summary Responsible for issuing and entering authorizations for specialty referrals, initial physical therapy, occupational therapy, speech therapy, inpatient and outpatient surgery, allergy testing, pharmacy services and exceptions for provider gaps.
Essential Functions
  • 1. Coordinates authorizations including specialty referrals, initial physical therapy, initial speech therapy, initial occupational therapy, outpatient therapy, allergy testing, exceptions for provider gaps, pharmacy services and DME.
  • 2. Authorizes referrals by obtaining and documenting information and verifying eligibility.
  • 3. Identifies physician provider utilization problems, quality and/or provider relations problems. Refers appropriate problems to PCC supervisor for resolution.
  • 4. Investigates issues or pending claims as needed.
  • 5. Coordinates letters to members, providing written notice of denied services.
  • 6. Provides physicians and facilities with notice of services authorized, visits, and expiration dates.
  • 7. Presents a positive image of Triton Health Systems, for members, providers, facilities, and the community both over the telephone and by appearance.
  • 8. Assists with coordinating the review process on all pending claims for the Medical Management area by monitoring: a. Member eligibility b. Interpretation and application of health benefits according to product c. Appropriate authorization d. Accurate date of service e. Timeliness according to established goal f. Monthly statistics
  • 9. Documents all determinations on the appropriate routing form to assure accurate adjudication of the claim.
  • 10. Assists with continuous education of providers and their staff through verbal and written communication.
Qualifications Current LPN license required. Utilization review experience preferred. Must use proper grammar, both written and oral. Experience with typing or data entry. Must be courteous to others.
Physical Qualifications Must be able to cope with an increased level of dust in the air. Must be able to work under pressure from deadlines and goals. Must be able to spend a large part of the day sitting at cube, desk or table Requires repetitive wrist, hand or finger movement
Additional Responsibilities Other duties as assigned. The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties, and tasks required of the individual as classified.


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