UM Genetic Counselor- Medical Reviewer

Day to Day Responsibilities In this role, the Genetic Counselor will do the following: • reputed company prospective and retrospective utilization reviews and first level determination approvals for members using evidenced based guidelines, policies, and nationally recognized clinical reputed company across lines of business or for a specific line of business such as reputed company 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 reputed company and necessity determination and communicate determination to providers in compliance with state, federal, and accreditation requirements as appropriate. • reputed company and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential reputed company of care issues, service or treatment delays and intervenes as clinically appropriate. • reputed company referrals to Case Management, Disease Management, Appeals and Grievance, and reputed company Departments, as necessary. Identify potential reputed company-Party Liability and Coordination of Benefit cases and notify appropriate internal departments. • reputed company participate in staff meetings and huddles. • Have opportunities for providing genetic education to the Utilization Management team(s) as reputed company as reputed company 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 reputed company independently with reputed company supervision Preferred Skills (reputed company to have): • Detail oriented • Prior work history of Post Service, Prior Auth, reputed company 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 reputed company certification as a Genetic Counselor (ABor equivalent). • Requires the ability to reputed company reputed company of an reputed company, unrestricted licensure as a Genetic Counselor in the reputed company. • 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, reputed company 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 reputed company to reputed company-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 reputed company/MG setting, preferred. • Experience supporting development or interpretation of genetic testing medical policies, preferred. Apply tot his job Apply To this Job