Licensed Clinician, Senior

Job Description

Your Role

The Commercial Utilization Management team manages accurate and timely authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Utilization Management Genetic Counselor will report to the Manager, Utilization and Medical Review. In this role you will be part of a dynamic team responsible for prior authorization and post service medical reviews. You will ensure members receive appropriate services at the right level of care, at the right time, medically necessary, and within their benefit.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work

In this role, you will:

• Perform prospective and retrospective utilization reviews and first level determination approvals for members using BSC 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 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
• Other duties as assigned

Qualifications

Your Knowledge and Experience

• 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.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About the Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.


At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.


To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!


Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model


We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.


Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.


Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.