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. GeneDx is at the forefront of transforming healthcare through its industry-leading exome and genome testing and interpretation services, fueled by the world’s largest, rare disease data sets. For more information, please visit www.genedx.com. 

Summary   

The Clinical Billing Integrity Lead Analyst will support the organization’s efforts in ensuring that all utilization requests 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, billing and 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 ensure accurate reimbursement. 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 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 

People Manager 

• No  

Education, Experience, and Skills 

• Master's Degree in Genetic Counseling or related field  

• Minimum of 3 years of experience, 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. 

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 is a fully remote position. The employee will work from a home office or other suitable 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 be established in collaboration with your leader and may be adjusted to align with evolving business needs. 

#LI-REMOTE