Clinical Billing Integrity Lead Analyst

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

Pay Transparency, Budgeted Range
$100,000—$120,000 USD

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Science - Minded, Patient - Focused.

At GeneDx, we create, follow, and are informed by cutting-edge science. With over 20 years of expertise in diagnosing rare disorders and diseases, and pioneering work in the identification of new disease-causing genes, our commitment to genetic disease detection, discovery, and diagnosis is based on sound science and is focused on enhancing patient care.

Experts in what matters most.

With hundreds of genetic counselors, MD/PhD scientists, and clinical and molecular genomics specialists on staff, we are the industry’s genetic testing experts and proud of it. We share the same goal as healthcare providers, patients, and families: to provide clear, accurate, and meaningful answers we all can trust.

SEQUENCING HAS THE POWER TO SOLVE DIAGNOSTIC CHALLENGES.

From sequencing to reporting and beyond, our technical and clinical experts are providing guidance every step of the way:

TECHNICAL EXPERTISE

• High-quality testing: Our laboratory is CLIA certified and CAP accredited and most of our tests are also New York State approved.

• Advanced detection: By interrogating genes for complex variants, we can identify the underlying causes of conditions that may otherwise be missed.

CLINICAL EXPERTISE

• Thorough analysis: We classify variants according to our custom adaptation of the most recent guidelines. We then leverage our rich internal database for additional interpretation evidence.

• Customized care: Our experts review all test results and write reports in a clear, concise, and personalized way. We also include information for research studies in specific clinical situations.

• Impactful discovery: Our researchers continue working to find answers even after testing is complete. Through both internal research efforts and global collaborations, we have identified and published hundreds of new disease-gene relationships and developed novel tools for genomic data analysis. These efforts ultimately deliver more diagnostic findings to individuals.

Learn more About Us here.

Our Culture

At GeneDx, we are dedicated to cultivating an environment where creativity and innovation thrive. We believe in the power of community and collaboration, where diverse perspectives are embraced, and every voice contributes to our shared success. Our team is a vibrant mix of professionals who challenge and support each other in equal measure, fostering growth both personally and professionally. When you join us, you're not just taking on a job—you're joining a movement. A movement that champions curiosity, embraces change, and believes in making an impact, one patient at a time. Cultural principles we live by:  

• Be bold in our vision & brave in our execution. 

• Communicate directly, with empathy. 

• Do what we say we're going to do.  

• Be adaptable to change.  

• Operate with a bias for action.  

Benefits include:

• Paid Time Off (PTO)

• Health, Dental, Vision and Life insurance

• 401k Retirement Savings Plan

• Employee Discounts

• Voluntary benefits

GeneDx is an Equal Opportunity Employer.

All privacy policy information can be found here.