Organization:
SHSO-Sutter Health System Office-Valley
Position Overview:
Responsible for assisting with assigning work to staff and day-to-day operations. Provides functional guidance and direction to the staff. Maintains statistics for the department and ensures established turnaround times are adhered to. Reviews daily work volumes of the referral pools and distributes work accordingly. Reviews, modifies, and researches, as directed to make recommendations to update policies and procedures to improve referral and authorization processing.
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:
Referral Entry Function:
- Able to perform all referral tasks and functions.
- Monitors and resolves referral/authorization orders in a timely manner.
- Monitors daily urgent and pending referrals to ensure timeliness standards are met and customer service is maximized according to standard workflows.
- 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.
- Assigns daily workload and monitors referrals, call queues, and fax box for proactive approach
- Reviews confidential clinical information and determines whether requested/required services are available within the medical network (entities, programs, and affiliated and aligned specialists).
- Identifies specialists and programs available within the 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.
Lead Responsibilities and Staff Support:
- Monitors and resolves referral/authorization orders in a timely manner.
- Assists manager with the assigning of the work to staff of the day-to-day operations by reviewing daily referral volumes and distributes work accordingly.
- Serves as a resource for the staff and provides functional guidance, including but not limited to training and mentoring new hires and ongoing training support for staff.
- Serves as an escalation point for patient and provider inquiries related to turnaround times that do not meet standards.
- Assists manager by researching, reviewing, and making modifications as necessary on policies and procedures.
- Assists manager by reviewing errors submitted by staff, patients and/or in discovery through audits.
- Assists stakeholder groups in resolving less complex planning issues.
- Manages multiple projects, including facilitating meetings, establishing work plans and timelines.
- Proactively seeks bottlenecks and referral delays via WQ management and tracking.
- Organized, host effective time management, self-efficiency and self-managed.
Communication:
- 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.
- Responds to emails, customer concerns or escalated referrals in a timely and professional manner.
- Able to prepare and present less complex projects to senior leadership.
- Communicates effectively and professionally.
PERFORMANCE MANAGEMENT AND CONTINUOUS IMPROVEMENT:
- Seeks and responds to regular performance feedback to staff, peers and leadership. This includes providing feedback and coaching to staff.
- 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.
- Creates and maintains effective relationships with customers, peers, colleagues, and leaders.
- Takes initiative in department and project teams.
- Demonstrates solid analytics and problem-solving skills.
- Working knowledge of patient/member/department, financial, operations and competitive data.
- Takes responsibility for portions of deliverables with management oversight.
EDUCATION:
Equivalent experience will be accepted in lieu of the required degree or diploma.
Bachelor's: Business and/or Healthcare Administration, or related field.
TYPICAL EXPERIENCE:
4 years 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 $42.41 to $63.62 / 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.
