Medical Review

Payrate: $50.00- $55.00/hr.
 
Summary
The Company is seeking an experienced Genetic Counselor to support utilization management activities for the Federal Employee Program. This role is responsible for conducting clinical reviews of prior authorization requests, evaluating medical necessities, ensuring compliance with medical policies and contractual requirements, and supporting evidence-based decision-making processes. The Genetic Counselor will collaborate with Medical Directors, providers, and internal departments while ensuring regulatory and accreditation compliance. This position also offers opportunities to provide genetics-focused education and contribute to the development and review of genetic testing medical policies.
 
Responsibilities

• Perform pre-service utilization reviews and first-level determination approvals for members using evidence-based guidelines, medical policies, and nationally recognized clinical criteria.
• Conduct clinical reviews of prior authorization requests to evaluate medical necessity, coding accuracy, medical policy compliance, and contract compliance.
• Prepare and present cases to Medical Directors for second-level review, oversight, and necessity determinations.
• Communicate utilization review determinations to providers in compliance with applicable state, federal, and accreditation requirements.
• Develop, review, and maintain member-centered documentation and correspondence that reflects determinations and comply with regulatory and accreditation standards.
• Identify potential quality-of-care concerns, service delays, or treatment delays and intervene as clinically appropriate.
• Facilitate referrals to Case Management, Disease Management, Appeals and Grievance, and Quality departments when necessary.
• Identify potential Third-Party Liability and Coordination of Benefits cases and notify the appropriate internal departments.
• Actively participate in staff meetings, team huddles, and collaborative discussions.
• Provide genetic education and subject matter expertise to Utilization Management teams.
• Contribute recommendations and clinical input related to genetic testing medical policy reviews and updates.
• Maintain accurate clinical documentation and support quality improvement initiatives.
• Apply clinical judgment and evidence-based practices while ensuring adherence to utilization management standards and organizational requirements.

 
Education Requirements

• Master’s degree in Genetic Counseling from a program accredited by the Accreditation Council for Genetic Counseling (ACGC).

 
Experience Requirements

• Minimum of 3 to 5 years of relevant experience as a Genetic Counselor.
• Strong clinical knowledge of molecular, cellular, and genetic medicine.
• Experience with somatic and germline genetic testing, carrier screening, prenatal testing, newborn testing, and neonatal intensive care environments.
• Experience working with utilization management principles, medical necessity reviews, regulatory requirements, and accreditation standards.
• Experience in a managed care, clinical, health plan, ASO, or IPA/MG environment is preferred.
• Experience supporting the development, interpretation, or review of genetic testing medical policies is preferred.

 
Required Skills

• Current certification as a Genetic Counselor (ABGC or equivalent).
• Ability to provide proof of active, unrestricted Genetic Counselor licensure in the State of California.
• Knowledge of utilization management processes and medical necessity review principles.
• Understanding of regulatory and accreditation requirements, including CMS, DHCS, NCQA, DMHC, and URAC standards.
• Strong analytical and clinical decision-making skills.
• Excellent documentation and written communication skills.
• Ability to evaluate and interpret complex clinical and genetic information.
• Strong computer proficiency with Windows-based applications and systems.
• Ability to collaborate effectively with physicians, providers, and cross-functional teams.
• Strong organizational skills and attention to detail.

 
Preferred Skills

• Experience within a health plan, ASO, or IPA/MG setting.
• Experience supporting the development or interpretation of genetic testing medical policies.
• Ability to provide genetics-related education and training to clinical and utilization management teams.
• Knowledge of evolving genetic testing technologies and clinical applications.

 
Pay Transparency: The typical base pay for this role across the U.S. is: $50.00 - $55.00 /hour. Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, health savings accounts with qualified medical plan enrollment, 10 paid days off, 3 days paid bereavement leave, 401(k) plan participation with employer match, life and disability insurance, commuter benefits, dependent care flexible spending account, accident insurance, critical illness insurance, hospital indemnity insurance, accommodations and reimbursement for work travel, and discretionary performance or recognition bonus. Sick leave and mobile phone reimbursement provided based on state or local law. 
 
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