Transfer & Referral Specialist II

Sutter Health; Sacramento (CA); Presencial; USD 39.000 - 72.000; Jornada completa

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Benefits

Descripción de la vacante

Sutter Health is seeking a Referral Specialist to manage confidential clinical information and coordinate specialty referrals within our network. You will work with physicians, clinics, and payers to route referrals to the right resources.

Responsibilities include reviewing requests, verifying coverage, and communicating with clinicians to ensure timely access to services. Strong knowledge of managed care and HIPAA is essential.

Formación

• Knowledge of managed care requirements and processes.
• Understanding of system, affiliate and community resources and third-party payers.
• Familiar with insurance authorization processes and HIPAA requirements.
• Ability to assess referral requests and determine appropriate level of care.

Responsabilidades

• Receives calls, collects clinical and insurance information, and identifies appropriate referral.
• Reviews information and determines services available within the medical network.
• Identifies specialists and facilitates patient referrals per payer rules and relationships.
• Provides assistance to clinicians needing specialty referrals for complex cases.

Conocimientos

Managed care knowledge

Insurance networks

HIPAA compliance

Referral workflow

Communication skills

Customer service

Interpersonal skills

Educación

Bachelor's in Business and/or Healthcare Administration, or related field

Herramientas

CRM systems

EMR / EHR

Referral tracking software

Descripción del empleo

We are so glad you are interested in joining Sutter Health!

Organization

SHSO-Sutter Health System Office-Valley

Position Overview

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 Description

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

Job Accountabilities

• 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.

Education

Equivalent experience will be accepted in lieu of the required degree or diploma.

Bachelor's in Business and/or Healthcare Administration, or related field.

Typical Experience

2 years of recent relevant experience.

Skills And Knowledge

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 HIPPA 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.

Job Shift

Days

Schedule

Full Time

Shift Hours

8

Days Of The Week

Monday - Friday

Weekend Requirements

Occasionally

Benefits

Yes

Unions

No

Position Status

Non-Exempt

Weekly Hours

40

Employee Status

Regular

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. Eligible positions also include a comprehensive benefits package.