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Genetic Counselor Review Associate

Carelon Medical Benefits Management

Schedule: 9:30-6 Central time

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.

• 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 center—connecting 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 will be responsible for conducting routine and simple reviews for genetic testing cases by following policies and procedures. Partners with senior reviewers and leaders to support complex pre-authorization, out of network, and appropriateness reviews by utilizing appropriate policies, clinical standards, and department guidelines. Learns to conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

• Receives pre-authorization requests from front-line intake.
• Conducts initial medical necessity clinical screening for simple and routine review cases.
• Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review for simple and routine cases.
• Works closely with medical directors to review and make recommendations regarding medical necessity of genetic test requests.
• Works closely with senior reviewers and leaders on complex cases for utilization management, out of network, and appropriateness of treatment.
• Coordinates with providers about the process and updates on cases.
• Notifies ordering physician or rendering service provider office of the pre-authorization decision.
• Documents the results of the initial clinical review and determination in the pre-certification computer system.
• Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network.
• Conducts review of grievance and appeals requests to provide to Medical Directors.
• Maintains confidentiality of patient and provider specific information.
• Develops telephone service standards to meet departmental performance metrics.

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

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

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.