[Hiring] Transfer & Referral Specialist II @Sutter Health

Role Description

Reviews confidential clinical information and provides personalized referrals to individuals or physicians/clinics requiring specialty services from a contracted medical group, hospital, or third-party payor. Facilitates referrals to appropriate Sutter facility, program or affiliated and aligned specialists.

(Intended for use by SCAH, SHSO, and SMCS only)

Job Accountabilities:

Tertiary Patient Referrals:

• Receives calls from internal or external sources, collects necessary clinical and insurance information, and identifies appropriate service, program and/or specialist applicable to referral request.
• Reviews confidential clinical information and determines whether requested/required services are available within the medical network (affiliates, programs, and affiliated and aligned specialists).
• Identifies specialists and programs available within system, and facilitates patient referral based on payer rules and regulations, specialist’s capacity, and contractual relationships.
• Provides assistance to clinicians needing specialty referrals for challenging/complex cases.

Documentation and Audit:

• Enters referral requests into database, documenting the interaction, actions taken, and appropriate information, including follow-up tracking.
• Performs peer-to-peer auditing for tertiary referrals.
• Performs foundation and Hospital Outpatient Department (HOD) referral auditing as requested.

Communication:

• Ensures physician/case management follow-up communication is timely.
• Creates patient communication (e.g. maps, appointment letter, etc.).
• Meets regularly with referral sources to ensure understanding of processes.
• Interacts with specialists and physicians to maintain current list of available and/or new clinical procedures/capabilities, and stay abreast of current fee schedules and contracting arrangements.
• Communicates regularly with affiliate staff to maintain understanding of entity’s service capabilities.

Performance Management and Continuous Improvement:

• Seeks and responds to regular performance feedback.
• Supports and assists the team when necessary.
• Contributes ideas and actions toward continuous improvement of processes and workflows.
• Recognizes and communicates potential issues to appropriate leader.

Qualifications

• Bachelor's in Business and/or Healthcare Administration, or related field.
• Equivalent experience will be accepted in lieu of the required degree or diploma.

Requirements

• 2 years of recent relevant experience.
• Working knowledge of managed care requirements and processes.
• Knowledge of system, affiliate and community resources, and third-party payers (e.g., PPO, HMO, Medicare, insurance plans).
• Knowledge of insurance authorization process and HIPAA requirements.
• Familiar with medical and managed care terminologies.
• Understanding of disease process to assess referral requests and appropriate level/provider of care required.
• Ability to define issues, collect data, establish facts and draw valid conclusions.
• Displays a customer service focus in all decisions and actions.
• Ability to communicate through verbal and written means, and to present information to a variety of audiences.
• Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.
• Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.
• Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.
• Demonstrates initiative in providing feedback/input to improve workflow/processes.
• Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.
• Ability to maintain and work discreetly with confidential and sensitive information.
• Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.

Benefits

• Comprehensive benefits package.

Company Description

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $28.00 to $52.56 / hour. The posted pay range is based on the position's primary work location. Candidates who reside and work outside of that location may be subject to a different pay range based on their work location. Candidate starting salaries consider multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program.