Associate Genetic Counselor Reviewer

Associate Genetic Counselor Reviewer

Genetic Counselor Review Associate

Carelon Medical Benefits Management

Schedule:

9:30-6 Central time

Virtual:
This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals.

While our roles may differ, our purpose is shared: to make a positive impact on whole health.

The Genetic Counselor Review Associate will be responsible for conducting routine and simple reviews for genetic testing cases by following policies and procedures. Partners with senior reviewers and leaders to support complex pre-authorization, out of network, and appropriateness reviews by utilizing appropriate policies, clinical standards, and department guidelines. Learns to conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

How you will make an impact:

• Receives pre-authorization requests from front-line intake.
• Conducts initial medical necessity clinical screening for simple and routine review cases.
• Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review for simple and routine cases.
• Works closely with medical directors to review and make recommendations regarding medical necessity of genetic test requests.
• Works closely with senior reviewers and leaders on complex cases for utilization management, out of network, and appropriateness of treatment.
• Coordinates with providers about the process and updates on cases.
• Notifies ordering physician or rendering service provider office of the pre-authorization decision.
• Documents the results of the initial clinical review and determination in the pre-certification computer system.
• Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network.
• Conducts review of grievance and appeals requests to provide to Medical Directors.
• Maintains confidentiality of patient and provider specific information.
• Develops telephone service standards to meet departmental performance metrics.

Minimum Requirements:

Requires MA/MS from an ACGC (Accreditation Counsel for Genetic Counseling) accredited program. ABGC (American Board of Genetic Counseling) board certification required. Preferred Skills, Capabilities and Experiences:

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

Job Level: Non-Management Non-Exempt

Workshift:
Job Family: MED >
Licensed/Certified - Other