Our client, a leading California-based health plan serving
4.7 million members
with over
$22.9 billion in annual revenue
, is seeking an experienced
UM Genetic Counselor / Medical Reviewer
to join its Utilization Management team.
This fully remote opportunity is ideal for an experienced
California-licensed Genetic Counselor
with a strong background in
utilization management, medical necessity reviews, prior authorization, and genetic testing
across Commercial and Medicare populations.
Position Details
• Position:
UM Genetic Counselor / Medical Reviewer
• Location:
Remote – California
• Duration:
3+ Month Contract (Likely Extension or Full-Time Conversion)
• Schedule:
Monday–Friday | 8:00 AM – 4:30 PM
• Hours:
40 hours/week
• Pay Rate:
$60–$68/hour W2
(Depending on Experience)
Position Overview The UM Genetic Counselor / Medical Reviewer performs prospective and retrospective utilization reviews, evaluates prior authorization requests, and supports evidence-based medical necessity determinations using nationally recognized clinical guidelines, medical policies, and regulatory standards.
This position also serves as a genetics subject matter expert by educating Utilization Management teams and contributing to the development and enhancement of genetic testing medical policies.
Key Responsibilities
• Perform prospective and retrospective utilization reviews and first-level medical necessity determinations using evidence-based guidelines and nationally recognized clinical criteria across Commercial, Medicare, and other lines of business.
• Review prior authorization requests for:
• Medical necessity
• Coding accuracy
• Medical policy compliance
• Contract compliance
• Prepare and present cases to the Medical Director for second-level review and medical necessity determination.
• Communicate review determinations to providers while ensuring compliance with state, federal, and accreditation requirements.
• Develop member-centered documentation and correspondence that meets regulatory and accreditation standards.
• Identify potential quality of care concerns, treatment delays, or service issues and intervene appropriately.
• Coordinate referrals to Case Management, Disease Management, Appeals & Grievance, and Quality departments.
• Identify potential Third-Party Liability (TPL) and Coordination of Benefits (COB) cases and notify appropriate internal teams.
• Participate in staff meetings and team huddles.
• Provide genetic education to Utilization Management teams.
• Recommend updates and enhancements to genetic testing medical policies.
Required Qualifications
• Master's degree in Genetic Counseling from an Accreditation Council for Genetic Counseling (ACGC) accredited program.
• Current ABGC (or equivalent) Genetic Counselor certification.
• Active, unrestricted Genetic Counselor license in the State of California.
• Minimum
5 years
of relevant experience with expertise in:
• Molecular, cellular, and genetic medicine
• Somatic and germline genetic testing
• Carrier screening
• Prenatal testing
• Newborn screening
• Neonatal ICU (NICU)
• Working knowledge of:
• Utilization Management
• Medical Necessity Review
• CMS
• DHCS
• NCQA
• DMHC
• URAC requirements
• Strong analytical, clinical decision-making, and documentation skills.
• Strong computer proficiency with Windows-based applications.
• Ability to work independently with minimal supervision.
Preferred Qualifications
• Previous experience with a Health Plan, ASO, IPA, or Medical Group (MG).
• Experience developing or interpreting genetic testing medical policies.
• Experience with:
• Post Service Reviews (highly preferred)
• Prior Authorization
• Concurrent Review
• Strong attention to detail.
• California residents preferred.
Why Apply?
• Fully remote California opportunity
• Competitive W2 pay
• 40-hour work week
• Opportunity for contract extension or full-time conversion
• Work with one of California's largest healthcare organizations
Apply today if you are a California-licensed Genetic Counselor with Utilization Management and medical review experience.
Recruiter Contact Info
Sajag Bhardwaj
Email: