Job Title: UM Genetic Counselor – Medical Reviewer
Location: Remote (Candidate must reside in California)
Duration: 3+ Months (Likely Extension | Contract-to-Hire)
Schedule: Monday–Friday | 8:00 AM – 4:30 PM | 40 Hours/Week
Pay Rate: $60-65.00/hr
Job Summary
We are seeking an experienced UM Genetic Counselor – Medical Reviewer to support a growing Utilization Management team by performing prospective and retrospective utilization reviews, evaluating prior authorization requests, and ensuring compliance with evidence-based clinical guidelines and regulatory standards.
Key Responsibilities
- Perform prospective and retrospective utilization reviews using evidence-based clinical guidelines.
- Review prior authorization requests for medical necessity, coding accuracy, medical policy, and contract compliance.
- Prepare and present complex cases to the Medical Director for second-level review and determination.
- Communicate authorization determinations to providers in accordance with state, federal, and accreditation requirements.
- Develop member-centered documentation and correspondence that meets regulatory standards.
- Identify quality of care concerns, treatment delays, and initiate appropriate interventions.
- Refer members to Case Management, Disease Management, Appeals & Grievance, and Quality departments as appropriate.
- Identify potential Third-Party Liability (TPL) and Coordination of Benefits (COB) cases.
- Participate in team meetings and utilization management huddles.
- Provide genetic education to Utilization Management teams.
- Support the review and development of genetic testing medical policies.
Required Qualifications
- Master's Degree in Genetic Counseling from an ACGC-accredited program.
- Current ABGC (or equivalent) Genetic Counselor certification.
- Active, unrestricted California Genetic Counselor license.
- Minimum 5 years of relevant experience in genetic counseling.
- Strong clinical knowledge of:
- Molecular, cellular, and genetic medicine
- Somatic and germline genetic testing
- Carrier screening
- Prenatal, newborn, and NICU genetic testing
- Working knowledge of Utilization Management and medical necessity review.
- Familiarity with CMS, DHCS, NCQA, DMHC, and URAC regulations.
- Strong analytical, clinical decision-making, documentation, and computer skills.
Preferred Qualifications
- Previous experience in a Health Plan, ASO, or IPA/Medical Group environment.
- Experience with Post Service, Prior Authorization, or Concurrent Review.
- Experience supporting genetic testing medical policy development or interpretation.
Pay: $60.00 - $65.00 per hour
Education:
Experience:
- Genetic counseling: 5 years (Required)
License/Certification:
- Certified Genetic Counselor (CGC) (Required)
- ABGC (Required)
Location:
Work Location: Remote
