Genetic Counselor Review Associate

Genetic Counselor Review Associate

Genetic Testing Utilization Review

Carelon Medical Benefits Management

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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

• Please note that per our policy on hybrid/virtual work candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment unless an accommodation is granted as required by law.

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 centerconnecting 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 is responsible for authorization requests and determining their appropriateness per designated clinical guidelines clinical policies and client rules. The GCRA will collaborate with healthcare providers to promote the highest quality and efficient use of member benefits.

How you will make an impact:

• 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.

• Maintains confidentiality of patient and provider specific information.

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 working in a cross functional team environment preferred.

• Experience and/or familiarity with reimbursement coding for genomic testing (e.g. CPT ICD-10CM) as relevant to testing preferred.

• 2 years expereince in lab or genetic counselor.