ClinicalBillingIntegrityLeadAnalyst

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 techno