Note: The job is a remote job and is open to candidates in USA. GeneDx delivers genomic and clinical insights that support diagnosis, treatment, and precision medicine. The Clinical Billing Integrity Lead Analyst ensures utilization requests and claim submissions meet payer medical necessity requirements by reviewing documentation, coding, prior authorizations, and denials, while developing clinical materials, improving processes, and analyzing data to strengthen reimbursement outcomes.
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 prior authorization 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
- • Master's Degree in Genetic Counseling or related field
- • Minimum of 3 years of experience
- • Demonstrated experience in genetic and molecular billing operations and medical necessity criteria
- • Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS)
- • Excellent communication, organizational, and problem-solving skills
- • Certification by the American Board of Genetic Counseling (ABGC) or equivalent
- • Genetic counseling state licensure as required by law
- This is a fully remote position. The employee will work from a home office or other suitable remote location with reliable high-speed internet access
- Lab and/or payer experience preferred
- • Experience with Medicare, Medicaid, and Commercial plans preferred
Benefits
- Fully remote position
- Competitive compensation and benefits that reflect local market practices and legal requirements in each country where we operate
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