Transfer & Referral Specialist II

Sutter Health•Sacramento, CA

3d•$28 - $53

About The Position

Reviews confidential clinical information and provides personalized referrals to individuals or physicians and clinics seeking specialty services from a contracted medical group, hospital, or third-party payor. Facilitates referrals to appropriate Sutter facilities, programs, and affiliated or aligned specialists. The role receives referral inquiries, gathers clinical and insurance details, assesses available services, and coordinates referrals in accordance with payer rules, specialist capacity, and contractual relationships. It also documents and audits referrals, maintains timely communication with physicians, case management, referral sources, specialists, and affiliate staff, and contributes to team support and continuous process improvement.

Requirements

Bachelor’s degree in Business and/or Healthcare Administration, or a related field; equivalent experience may be accepted in lieu of the required degree or diploma.
Two years of recent relevant experience.
Working knowledge of managed care requirements and processes.
Knowledge of system, affiliate, and community resources and third-party payers, such as PPOs, HMOs, Medicare, and insurance plans.
Knowledge of insurance authorization processes and HIPAA requirements.
Familiarity with medical and managed care terminology.
Understanding of disease processes to assess referral requests and the appropriate level or provider of care.
Ability to define issues, collect data, establish facts, and draw valid conclusions.
Customer-service focus in decisions and actions.
Ability to communicate verbally and in writing and present information to varied audiences.
Organization skills to manage or reprioritize activities and projects to meet deadlines while maintaining responsiveness.
Ability to interact and maintain effective working relationships with people contacted in performing required duties.
Respect for cultural and linguistic differences and commitment to an inclusive work environment.
Initiative in providing feedback and input to improve workflows and processes.
Ability to work effectively in a dynamic, fast-paced environment with changing business priorities.
Ability to handle confidential and sensitive information discreetly.
Ability to use essential applications and databases associated with the role’s duties and responsibilities.

Responsibilities

Receive internal and external calls, collect clinical and insurance information, and identify the appropriate service, program, or specialist for each referral request.
Review confidential clinical information and determine whether requested or required services are available within the medical network.
Identify system specialists and programs and facilitate patient referrals based on payer rules and regulations, specialist capacity, and contractual relationships.
Assist clinicians with specialty referrals for challenging or complex cases.
Enter referral requests into a database, document interactions and actions, and track follow-up.
Perform peer-to-peer auditing for tertiary referrals.
Perform foundation and Hospital Outpatient Department (HOD) referral auditing as requested.
Ensure timely follow-up communication with physicians and case management.
Create patient communications, such as maps and appointment letters.
Meet regularly with referral sources to ensure they understand referral processes.
Interact with specialists and physicians to maintain current information on clinical procedures and capabilities, fee schedules, and contracting arrangements.
Communicate regularly with affiliate staff to maintain understanding of each entity’s service capabilities.
Seek and respond to regular performance feedback.
Support and assist the team when necessary.
Contribute ideas and actions toward continuous improvement of processes and workflows.
Recognize and communicate potential issues to the appropriate leader.