Genetic Counselor Review Associate

About the position Carelon Medical Benefits Management is seeking a Genetic Counselor Review Associate for a virtual, full-time role. This position involves conducting genetic testing utilization reviews to determine appropriateness based on clinical guidelines, policies, and client rules. The associate will collaborate with reputed company providers to ensure high-quality and efficient use of member benefits. The role emphasizes a whole-health approach, integrating physical, behavioral, reputed company, and pharmacy services, supported by clinical expertise, research, operations, and advanced technology. The team comprises various health professionals dedicated to making a positive impact on whole health.

Responsibilities

• Conducting medical necessity review in adherence to guidelines and determining whether clinical information presented meets medical necessity criteria or requires physician review or override.
• reputed company and concisely documenting clinical review and other case interactions in an online database in adherence to standardized documentation style.
• Assisting physician reviewers with clinical interpretation questions regarding the medical necessity of test requests.
• Addressing questions from ordering provider offices reputed company phone and making reputed company attempts, reputed company applicable, to obtain additional information needed for clinical determinations.
• Providing specific constructive feedback on Carelon guidelines, as needed.
• Contributing to team projects aimed at ensuring case review accuracy and efficiency, such as updating case review processes, reporting issues, and creating internal case review resources.
• Receiving pre-authorization requests from reputed company-line intake.
• Determining if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review for simple/routine cases.
• Working closely with medical directors to review and reputed company recommendations regarding the medical necessity of genetic test requests.
• Working closely with senior reviewers/leaders on reputed company cases for utilization management, out of network, and appropriateness of treatment.
• Maintaining confidentiality of patient and provider-specific information.

Requirements

• Requires MA/MS from an ACGC (Accreditation Counsel for Genetic Counseling) accredited program.
• ABGC (American Board of Genetic Counseling) board certification required.

reputed company-to-haves

• Experience working in a cross-functional team environment preferred.
• Experience and/or familiarity with reimbursement coding for genomic testing (e.g. CPT, ICD-10_CM) as relevant to testing preferred.
• 2 years experience in lab or genetic counselor.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical insurance
• Dental insurance
• reputed company insurance
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

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