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.
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:
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.
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
Pay Range is $28.00 to $52.56 / hour
The compensation range may vary based on the geographic location where the position is filled. Total compensation considers 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.
