Transfer & Referral Specialist Lead

Sutter Health•Sacramento, CA

About The Position

Responsible for assisting with assigning work to staff and day-to-day operations, providing functional guidance and direction, maintaining department statistics, and ensuring established turnaround times are met. The role reviews daily referral-pool volumes and distributes work accordingly, and researches and recommends updates to policies and procedures to improve referral and authorization processing. The specialist performs referral-entry functions, monitors and resolves referral and authorization orders, reviews urgent and pending referrals, and supports timely, customer-focused service. The role receives calls, collects clinical and insurance information, identifies appropriate services or specialists, and determines whether requested services are available within the medical network. It facilitates referrals in accordance with payer rules, specialist capacity, and contractual relationships, and assists clinicians with challenging or complex specialty referrals. As a lead, the position supports staff through workload distribution, training, mentoring, and functional guidance; serves as an escalation point for patient and provider inquiries; reviews errors; assists with policy and procedure updates; and manages multiple projects. The role also communicates with referral sources, specialists, physicians, affiliate staff, and leadership, supports continuous improvement, and handles confidential clinical and operational information.

Requirements

Bachelor's degree in Business and/or Healthcare Administration or a related field, or equivalent experience in lieu of the degree.
Four years of recent relevant experience.
Working knowledge of managed care requirements and processes.
Knowledge of system, affiliate, and community resources, as well as third-party payers such as PPO, HMO, 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.
Organizational skills to manage and reprioritize activities and projects while meeting deadlines and maintaining responsiveness.
Ability to interact and maintain effective working relationships with people contacted in the performance of required duties.
Ability to respect cultural and linguistic differences and promote 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.

Responsibilities

Perform all referral tasks and functions, and monitor and resolve referral and authorization orders in a timely manner.
Monitor urgent and pending referrals to ensure timeliness standards and customer-service expectations are met.
Receive calls, collect clinical and insurance information, and identify the appropriate service, program, or specialist for referral requests.
Assign daily workload and monitor referrals, call queues, and fax box activity.
Review confidential clinical information and determine whether requested services are available within the medical network.
Identify available specialists and programs and facilitate referrals based on payer rules, specialist capacity, and contractual relationships.
Assist clinicians with specialty referrals for challenging or complex cases.
Assist the manager with day-to-day work assignment by reviewing referral volumes and distributing work.
Provide functional guidance, training, and mentoring to staff, including new hires and ongoing training support.
Escalate and respond to patient and provider inquiries about turnaround times that do not meet standards.
Research and recommend modifications to policies and procedures.
Review errors reported by staff or patients or identified through audits.
Assist stakeholder groups with less complex planning issues.
Manage multiple projects, including facilitating meetings and establishing work plans and timelines.
Proactively identify bottlenecks and referral delays through work-queue management and tracking.
Meet with referral sources to ensure they understand processes.
Interact with specialists and physicians to maintain current information on clinical procedures, capabilities, fee schedules, and contracting arrangements.
Communicate with affiliate staff about entity service capabilities.
Respond to emails, customer concerns, and escalated referrals in a timely and professional manner.
Prepare and present less complex projects to senior leadership.
Provide feedback and coaching to staff, support the team, and contribute to continuous improvement of processes and workflows.
Recognize and communicate potential issues to the appropriate leader, take initiative on department and project teams, and maintain effective working relationships.