About the position Carelon Medical Benefits Management is seeking a Genetic Counselor Review Associate for a virtual, full-time role. This position involves conducting utilization reviews for genetic testing to determine appropriateness based on clinical guidelines, policies, and client rules. The associate will collaborate with healthcare providers to ensure the highest quality and efficient use of member benefits. The role emphasizes a whole-health approach, integrating physical, behavioral, social, and pharmacy services, supported by clinical expertise, research, operations, and advanced technology.

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 an online database in adherence to standardized documentation style.
• Assisting physician reviewers with clinical interpretation questions regarding the medical necessity of test requests.
• Addressing questions from ordering provider offices via phone and making outreach attempts, when applicable, to obtain additional information needed for clinical determinations.
• Providing specific constructive feedback on Carelon guidelines, as needed.
• Contributing to team projects aimed at ensuring case review accuracy and efficiency, such as updating case review processes, reporting issues, and creating internal case review resources.
• Receiving pre-authorization requests from front-line intake.
• Determining if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review for simple/routine cases.
• Working closely with medical directors to review and make recommendations regarding the medical necessity of genetic test requests.
• Working closely with senior reviewers/leaders on complex cases for utilization management, out of network, and appropriateness of treatment.
• Maintaining confidentiality of patient and provider specific information.

Requirements

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

Nice-to-haves

• Experience working in a cross-functional team environment.
• Experience and/or familiarity with reimbursement coding for genomic testing (e.g. CPT, ICD-10_CM) as relevant to testing.
• 2 years experience in lab or genetic counselor.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical insurance
• Dental insurance
• Vision insurance
• Short and long term disability benefits
• 401(k) with match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources