Remote Genomics Billing Integrity Lead

GeneDx, LLC; United States; Remote; USD 100,000 - 120,000; Full time

Job summary

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.

Qualifications

• 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.

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 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.

Skills

Medical coding knowledge

Data analysis

Communication skills

Problem solving

Education

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

Job description

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.