UM Genetic Counselor-Medical Reviewer
Remote from home in California
8am-5:00 PST
Reason For Assignment: 7000k claims in back log along with 15% increase in claims this FY
4+ months
 
Summary:
The main function of a Medical Reviewer is to ensure accuracy and compliance of healthcare documentation and information to confirm they meet regulatory standards.

Job Responsibilities:
Perform prospective and retrospective utilization reviews and first level determination approvals for members using 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 or 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.

Skills:
• Verbal and written communication skills, multi-tasking, customer service skills and interpersonal skills.
• Strong ability to work independently and manage one’s time.
• Strong ability to keep information organized and confidential.
• Must be proficient with access-like database and conducting most/all work activities on computer only.

Qualifications:
• 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 5 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. 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's pay range is $50.00/hr - $63.00/hr.