Clinical Billing Integrity Lead Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist in organizational initiatives to guarantee that utilization requests and claim submissions comply with payers' medical necessity regulations and standards.

• Implement payer-specific medical necessity guidelines for claims and prior authorization submissions.

• Ensure that clinical documentation substantiates the medical necessity of the services rendered.

• Collaborate closely with claims, coding, appeals, billing, and other internal clinical departments.

• Spearhead cross-functional clinical billing integrity initiatives for claims and invoices.

• Develop clinical resources, such as letters of medical necessity, pricing justification, and appeal templates.

• Review and evaluate prior authorization and claims denials for compliance, pinpointing documentation or coding discrepancies and potential appeal avenues.

• Establish and adhere to new processes or modifications to ensure compliance and desired outcomes.

• Incorporate new technologies and initiatives to summarize clinical information for pre- and post-test teams.

• Offer insights into emerging use cases for exome and genome sequencing.

• Provide Market Access insights regarding payer-specific coverage gaps and inconsistencies with industry standards.

• Analyze data trends utilizing PowerBI, Tableau, and Smartsheets to uncover opportunities for enhancing clinical billing integrity initiatives.

• Report directly to the Associate Director of Clinical Billing Integrity.

• No responsibilities for managing personnel.

⛳️ Requirements

• Master's Degree in Genetic Counseling or a related discipline.

• At least 3 years of relevant experience.

• Proven experience in genetic and molecular billing operations and medical necessity standards.

• Extensive knowledge of clinical documentation and medical coding (CPT, ICD-10, HCPCS).

• Certification from the American Board of Genetic Counseling (ABGC) or its equivalent.

• Genetic counseling state licensure as mandated by law.

• Preference for candidates with lab and/or payer experience.

• Experience with Medicare, Medicaid, and commercial plans is preferred.

• Exceptional communication, organizational, and problem-solving abilities.

• Dependable high-speed internet access.

• Proficient in using standard office equipment, including computers, phones, and video conferencing tools.

🏝️ Benefits

• Competitive salary and benefits that align with local market practices and legal requirements in each country where GeneDx operates.

• Fully remote work option from a home office or another suitable remote location.

• Flexible standard work schedule and hours set in collaboration with the leader, adaptable to business needs.

• Standard office equipment provided, including computers, phones, and video conferencing tools.