Associate Director, Billing Integrity

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 Associate Director of Clinical Billing Integrity will support the organization’s efforts in ensuring that all claims and invoices submitted to payers and other customers comply with medical necessity rules and requirements. This role includes the application of payer-specific medical necessity criteria to claims, ensuring that clinical documentation supports the medical necessity of services provided. The specialist will work closely with claims, coding, appeals and other internal clinical teams to ensure adherence to payer policies and regulatory guidelines, mitigating the risk of claim denials and success of appeals to ensure accurate reimbursement. 

 Job Responsibilities 

• Support clinical integrity efforts cross functionally to ensure adherence to medical necessity rules and payer-specific requirements for claims and invoices. 

• Review prior authorization requests and claims for compliance with medical necessity rules, identifying potential issues or discrepancies in clinical documentation and coding, and identifying opportunities for appeals. 

• Stay current on changes to payer medical necessity guidelines, policies, and healthcare regulations, ensuring all claims processes and procedures are updated accordingly. 

• Analyze payer claim denials related to medical necessity and billing integrity, work with appropriate teams to resolve issues, and implement corrective actions to reduce future denials. 

• Provide training and guidance to relevant internal teams on payer medical necessity requirements, claims standards, and best practices for documentation and coding. 

• Support inclusion of details derived from medical records in documentation to payers in relationship to medical necessity of testing. 

 People Manager 

• No 

• Anticipated opportunity to lead team of 3-4 payer specialists in the future. 

 Education, Experience, and Skills 

• Minimum of 5 years of experience with lab and/or payer claims management related to medical necessity rules. 

• Strong knowledge of payer medical necessity rules, insurance claims processing, and healthcare compliance standards for commercial and government payers. 

• Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS) to ensure accurate and complete claims submission. 

• Proven experience in managing claim denials and appeals related to medical necessity, including working with payers or labs to resolve issues. 

• Demonstrated ability to identify claims that meet payer criteria and provide written communication in support of reimbursement. 

• Experience utilizing claims data to identify unexpected outcomes and trends, perform root cause analysis, and inform process updates. 

• Master's Degree in Genetic Counseling or similar clinical degree with demonstrated experience in billing operations and medical necessity rules.  

• Excellent communication, organizational, and problem-solving skills. 

• High level of attention to detail and the ability to work under tight deadlines in a fast-paced environment. 

• Experience in a leadership/supervisory role preferred but not required. 

• Experience with claims management software and data analytics tools. 

 Physical Demands 

• Ability to stand and sit for extended periods. 

Work Environment  

• The role may require occasional travel about 10%. 

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