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Genetic Counselor Reviewers are responsible for conducting pre-authorization, out of network and appropriateness of genetic tests by utilizing appropriate policies, clinical and department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of genetic testing to ensure quality member outcomes, and to optimize member benefits.
These positions typically require office training, but due to COVID our offices are currently closed. We have approval to offer remote/virtual training and these positions will work full-time remote from home.
Location: Work from home
Schedule: Monday - Friday, 9:30 am to 6:00 pm PST/CST
Internet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps)
Primary duties may include, but are not limited to:
• Works closely with Medical directors to review and make recommendations regarding medical necessity of genetic test requests
• Receives pre-authorization requests from front-line intake
• Conducts initial medical necessity clinical screening
• Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
• Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network
• Notifies ordering physician or rendering service provider office of the pre-authorization determination decision
• Documents the results of the initial clinical review and determination in the pre-certification computer system
• 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
- Master’s Degree in Genetic Counseling, and/or MS or PhD in Human Genetics, Molecular Biology, or equivalent area of education and expertise from an ACGC accredited program.
- ABGC board-certified
- Active licensure in the state of residence, if applicable
- Experience working in a cross-functional team environment including both technical and non-technical colleagues
- Experience in clinical genetics and/or diagnostic laboratory preferred
- Experience in medical review and/or utilization management preferred.
- Experience with Oncology, Tumor Genetics and/or Somatic Genetics preferred
- Experience, familiarity, and/or willingness to quickly learn reimbursement coding for genomic testing (e.g., CPT, ICD-10-CM) as relevant to testing
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. 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 firstname.lastname@example.org for assistance.