In this role, the Genetic Counselor will do the following:
Perform prospective and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Commercial or Medicare.
Conduct 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 as clinically appropriate.
Provide referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments, as necessary. Identify potential Third-Party Liability and Coordination of Benefit cases and notify appropriate internal departments.
Actively participate in staff meetings and huddles.
Have opportunities for providing genetic education to the Utilization Management team(s) as well as provide input on suggested genetic medical policies updates.
Required Skills (top 3 non-negotiables):
Strong Clinical Judgement, RN/LVN minimum 2 years of experience
Strong computer skills
Works well independently with minimal supervision
Preferred Skills (nice to have):
Detail oriented
Prior work history of Post Service, Prior Auth, Concurrent review. Preferential interview consideration for Post Service experience.
Lives in California
Disqualifiers/Dislikes on Resumes:
Incomplete resumes with gaps in time or hasn't worked in a role recently
Education 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 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.