Clinical Billing Integrity Lead Analyst

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 including letters of medical necessity, pricing justification and appeal templates
• Review and decision prior authorization and claims denials for compliance with medical necessity rules
• Create and follow new processes to ensure compliance and intended outcomes
• Integrate new technology for summarization of clinical information
• Provide insight into new and emerging use cases for exome and genome sequencing
• Provide feedback for Market Access on payor specific gaps in coverage
• Analyze data trends using PowerBI, Tableau, or Smartsheets to find new opportunities for targeted expansion

Requirements

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

About the Company

GeneDx delivers personalized and actionable health insights to inform diagnosis, direct treatment, and improve drug discovery through genomic and large-scale clinical information.