The genetic counselor reviewer (GCR) is responsible for authorization requests and determining their appropriateness per designated clinical guidelines, clinical policies, and client rules. The GCR will collaborate with healthcare providers to promote the highest quality and efficient use of member benefits. Location: This position will work remote and must live within 50 miles of one of our Pulse Point office locations. How will you make an impact: Receiving authorization requests for genetic tests from front-line intake. 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. Assisting physician reviewers with clinical interpretation questions regarding medical necessity of test requests. Addressing clinical questions received via incoming call from ordering providers and triaging calls when appropriate. Occasionally performing callouts to case submitters to obtain missing clinical information. Providing specific constructive feedback on Carelon guidelines. Maintaining confidentiality of patient and provider specific information. Contributing 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. Minimum requirements: Requires MA/MS from an ACGC (Accreditation Counsel for Genetic Counseling) accredited program, and a minimum 3 years of experience in clinical genetics and/or diagnostic laboratory; or any combination of education and experience, which would provide an equivalent background. Active, unrestricted genetic counselor license is required in applicable states. ABGC (American Board of Genetic Counseling) board certification required. Preferred Skills, Capabilities, and Experiences: Motivation to exceed departmental metrics. Active, unrestricted genetic counselor license, especially in Florida, Georgia, Indiana, and/or Kentucky. Experience in utilization management and/or reimbursement coding for genetic testing. Experience with somatic oncology testing a plus. West Coast business hours are preferred, but not essential. Highly detailed-oriented. Escalates appropriate concerns or discrepancies. Works well both independently and as part of a team. Must be flexible and adaptable.
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