Job DescriptionYour RoleThe Commercial Utilization Management team manages accurate and timely authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Utilization Management Genetic Counselor will report to the Manager, Utilization and Medical Review. In this role you will be part of a dynamic team responsible for prior authorization and post service medical reviews. You will ensure members receive appropriate services at the right level of care, at the right time, medically necessary, and within their benefit.
ResponsibilitiesYour Work In this role, you will:
- Perform prospective and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Commercial or Medicare.
- Conducts 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
- Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
- Actively participates in staff meetings and huddles
- The Genetic Counselor will have opportunities for providing genetic education to the Utilization Management team(s) as well as provide input on suggested genetic medical policies updates.
QualificationsYour Knowledge and Experience- 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 7 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.
Hybrid This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
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