Our Client, a Health Insurance company, is looking for a Medical Review 5 for their Rancho Cordova¸ CA location.
Responsibilities:
Perform pre service utilization reviews and first level determination approvals for members using Client evidenced based guidelines, policies and nationally recognized clinal criteria for the Federal Employee Program.
Conducts clinical review of prior authorization requests for medical necessity, coding accuracy, medical policy compliance and contract compliance
Prepare and present cases to Medical Director (MD) for second level review oversight and necessity determination and communicate determination to providers in compliance with state, federal and accreditation requirements as appropriate.
Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
Actively participates in staff meetings and huddles
The Genetic Counselor will have opportunities for providing genetic education to the Utilization Management team(s) as well as provide input on suggested genetic medical policies updates.
Requirements:
Requires a master’s degree in Genetic Counseling from a program accredited by the Accreditation Council for Genetic Counseling (ACGC).
Requires a current certification as a Genetic Counselor (ABGC or equivalent).
Requires the ability to provide proof of an active, unrestricted licensure as a Genetic Counselor in the State of California
Requires at least 3-5 years of prior relevant experience which includes a strong clinical understanding of molecular, cellular, and genetic medicine and somatic and germline genetic testing, carrier screening, prenatal testing, newborn testing, and neonatal ICU.
Requires working knowledge of utilization management principles, including medical necessity review, regulatory requirements, and accreditation standards (e.g., CMS, DHCS, NCQA, DMHC, URAC)
Requires strong computer skills related to Windows-based programs and applications
Requires strong analytical, clinical decision-making, and documentation skills in a managed care or clinical environment.
Prior experience in health plan, ASO, or IPA/MG setting, preferred.
Experience supporting development or interpretation of genetic testing medical policies, preferred.