Clinical Billing Integrity Lead Analyst

GeneDx, LLC; United States; Remote; USD 100.000 - 120.000; Vollzeit

Zusammenfassung

GeneDx is seeking a Clinical Billing Integrity Lead Analyst to oversee payer policy adherence and medical necessity reviews for claims and prior authorizations. You will collaborate with claims, coding, and billing teams to minimize denials and improve reimbursement accuracy.

Fully remote role with a focus on integrating new processes and technology to summarize clinical information for pre- and post-test teams, while guiding Market Access on coverage gaps and evolving payer requirements.

Qualifikationen

• Master’s degree in Genetic Counseling or related field.
• Minimum of 3 years of lab and/or payer experience preferred.
• Demonstrated experience in genetic and molecular billing operations and medical necessity criteria.
• Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS).
• Experience with Medicare, Medicaid, and Commercial plans preferred.
• Excellent communication, organizational, and problem-solving skills.

Aufgaben

• Lead clinical integrity efforts cross-functionally to ensure adherence to medical necessity rules and payer-specific requirements for claims and invoices.
• Create clinical materials as appropriate including letters of medical necessity, pricing justification and appeal templates.
• Review and decision preauthorization and claims denials for compliance with medical necessity rules, identifying potential issues or discrepancies in clinical documentation and coding, and identifying opportunities for appeals.
• Create and follow new processes or process changes and to ensure compliance and intended outcomes as needed.
• Integration of new technology and initiatives for summarization of clinical information for both pre- and post-test teams.
• Provide insight into new and emerging use cases for exome and genome sequencing.
• Provide feedback for Market Access on payor-specific gaps in coverage and/or misalignment to industry standards.
• Analyze data trends, using a variety of data visualization tools (e.g., PowerBI, Tableau, Smartsheets) to find new opportunities for targeted expansion of clinical billing integrity team efforts.

Kenntnisse

Medical coding knowledge

Data analysis

Communication skills

Problem solving

Ausbildung

Masters degree in Genetic Counseling or related field

3+ years of lab and/or payer experience

ABGC certification or equivalent

Genetic counseling state licensure (as required by law)

Tools

Medicare knowledge

Medicaid knowledge

Commercial plans understanding

Jobbeschreibung

GeneDx(Nasdaq: WGS) delivers personalized and actionable health insights to inform diagnosis, direct treatment, and improve drug discovery. The company is uniquely positioned to accelerate the use of genomic and large-scale clinical information to enable precision medicine as the standard of care.GeneDxis at the forefront of transforming healthcare through its industry-leading exome and genome testing and interpretation services, fueled by the worlds largest, rare disease data sets. For more information, please visit www.genedx.com.

Summary

TheClinical Billing Integrity Lead Analystwill support the organization's efforts in ensuring that allutilizationrequests and claim submissions align to payers' medical necessity rules and requirements. This role includes the application of payer-specific medical necessity criteria to claims and prior authorization requests, ensuring that clinical documentation supports the medical necessity of services provided. The lead analyst will work closely with claims, coding, appeals,billingand other internal clinical teams to ensure adherence to payer policies and regulatory guidelines, mitigating the risk of claim denials and improving success of appeals to ensureaccuratereimbursement. This position directly reports to the Associate Director of Clinical Billing Integrity.

Job Responsibilities

• Lead clinical integrity efforts cross-functionally to ensure adherence to medical necessity rules and payer-specific requirements for claims and invoices.

• Create clinical materials asappropriate includingletters of medical necessity, pricingjustificationand appeal templates

• Review and decisionpriorauthorization and claims denials for compliance with medical necessity rules,identifyingpotential issues or discrepancies in clinical documentation and coding, andidentifyingopportunities for appeals.

• Create and follow new processes or process changes and to ensure compliance and intended outcomes as needed

• Integration ofnew technologyand initiatives for summarization of clinical information for both pre-and post-test teams

• Provide insight into new and emerging use cases for exome and genome sequencing

• Provide feedback for Market Access on payor specific gaps in coverage and/or misalignment to industry standards

• Analyze data trends, using a variety of data visualization tools (e.g.PowerBI, Tableau,Smartsheets) to find new opportunities for targeted expansion of clinical billing integrity team efforts

People Manager

• No

Education, Experience, and Skills

• Masters Degree in Genetic Counselingor related field

• Minimum of 3 years of experience,laband/or payer experience preferred.

• Demonstrated experience in genetic and molecular billing operations and medical necessity criteria.

• Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS)

• Experience with Medicare, Medicaid, and Commercialplanspreferred.

• Excellent communication, organizational, and problem-solving skills.

Certificates, Licenses, Registrations

• Certification by the American Board of Genetic Counseling (ABGC) or equivalent
• Genetic counseling state licensure as required by law.

Work Environment

This isa fullyremote position. The employee will work from a home office orothersuitable remote location with reliable high-speed internet access. Work is performed in a climate-controlled environment using standard office equipment including computer, phone, and video conferencing tools.Your standard work schedule and hours will beestablishedin collaboration with your leader and may be adjusted to align with evolving business needs.

#LI-REMOTE

Pay Transparency, Budgeted Range

$100,000-120,000 USD

A culture that plays to win, because patients are counting on us

At GeneDx, we're driven by urgency and purpose: helping patients get diagnosed earlier. Our mission, to empower everyone to live their healthiest life through genomics, drives our team to make a tangible impact each day - and shapes our culture where high standards, strong teamwork, and meaningful ownership are the norm. We act with intention, support one another, and deliver work we’re proud to put our names on.

Here’s what you can expect day to day:

1. Play like a champion (step up, redefine what's possible, own it)

   We bring energy, focus, and a bias for action. We step up, take initiative, and deliver on our commitments - with quality, speed, and care.

2. Think bigger (stretch beyond, courage not consensus)

   We push past the obvious. We challenge assumptions, raise the bar, and make thoughtful, decisive calls - choosing progress over perfection.

3. Grow fast (be curious, speak up, be agile)

   We stay curious, ask questions, and share direct feedback with respect. We adapt quickly and keep learning through collaboration and continuous improvement.

If you're motivated by meaningful work, a fast-moving environment, and teammates who care deeply about outcomes, you'll thrive at GeneDx.

At GeneDx, we believe in taking care of our people. We provide competitive compensation and benefits that reflect local market practices and legal requirements in each country where we operate, helping employees thrive both professionally and personally.

We welcome everyone regardless of their background. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sex, gender, gender identity, sexual orientation, protected veteran status, disability, age, and other characteristics protected by law.

GeneDx is a place where people from all backgrounds can make an impact.

All privacy policy information can be found here.