Genetic Counselor Review Associate

About the role

The Genetic Counselor Review Associate is responsible for conducting medical necessity reviews, assisting with clinical interpretation questions, and collaborating with healthcare providers to ensure the appropriate use of member benefits.

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.
• Clearly and concisely documenting clinical review and other case interactions in online database in adherence to our standardized documentation style.
• Assists physician reviewers with clinical interpretation questions regarding medical necessity of test requests.
• Addresses questions from ordering provider offices via phone and makes outreach attempts, when applicable, to obtain additional information needed for clinical determinations.
• Provides specific constructive feedback on Carelon guidelines, as needed.
• Contributes to team projects aimed to ensure case review accuracy and efficiency, such as updating case review processes, reporting issues, and creating internal case review resources.
• Receives pre-authorization requests from front-line intake.
• Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review for simple/routine cases.
• Works closely with medical directors to review and make recommendations regarding medical necessity of genetic test requests.
• Works closely with senior reviewers/leaders on complex cases for utilization management, out-of-network, and appropriateness of treatment.

Requirements

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

Preferred Skills, Capabilities, and Experiences

• 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 counseling.

Pay

Commensurate with experience.

Schedule

Full-time, with the exception of required in-person training sessions.