Transfer & Referral Specialist II

Sutter Health•Sacramento, CA

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, or affiliated and aligned specialists. This role is intended for use by SCAH, SHSO, and SMCS only. The position receives referral inquiries, gathers clinical and insurance information, determines appropriate services and referral destinations, and supports clinicians with challenging or complex specialty referrals. It documents referral activity and follow-up, conducts referral audits, coordinates communications with patients, physicians, case management, referral sources, specialists, and affiliates, and contributes to performance improvement and effective team operations.

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 determine appropriate level and provider of care.
Ability to define issues, collect data, establish facts, and draw valid conclusions.
Customer-service focus in decisions and actions.
Verbal and written communication skills, including the ability to present information to varied audiences.
Organization skills to manage or reprioritize activities and projects, meet deadlines, and remain responsive.
Ability to interact and maintain effective working relationships with people contacted in the course of 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 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 calls from internal or external sources, collect clinical and insurance information, and identify the service, program, or specialist appropriate to each referral request.
Review confidential clinical information and determine whether requested or required services are available within the medical network, including affiliates, programs, and affiliated and aligned specialists.
Identify specialists and programs available within the system and facilitate patient referrals in accordance with 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 and document interactions, actions taken, relevant information, and follow-up tracking.
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 keep current lists of available or new clinical procedures and capabilities, and stay informed about 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, and support the team when necessary.
Contribute ideas and actions to improve processes and workflows.
Recognize and communicate potential issues to the appropriate leader.