Licensed Clinician, Senior

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.

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.