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 <a href="http://www.genedx.com/">www.genedx.com</a>.   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  <ul> <li>Support clinical integrity efforts cross functionally to ensure adherence to medical necessity rules and payer-specific requirements for claims and invoices. </li> </ul> <ul> <li>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. </li> </ul> <ul> <li>Stay current on changes to payer medical necessity guidelines, policies, and healthcare regulations, ensuring all claims processes and procedures are updated accordingly. </li> </ul> <ul> <li>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. </li> </ul> <ul> <li>Provide training and guidance to relevant internal teams on payer medical necessity requirements, claims standards, and best practices for documentation and coding. </li> </ul> <ul> <li>Support inclusion of details derived from medical records in documentation to payers in relationship to medical necessity of testing. </li> </ul>  People Manager  <ul> <li>No </li> </ul> <ul> <li>Anticipated opportunity to lead team of 3-4 payer specialists in the future. </li> </ul>  Education, Experience, and Skills  <ul> <li>Minimum of 5 years of experience with lab and/or payer claims management related to medical necessity rules. </li> </ul> <ul> <li>Strong knowledge of payer medical necessity rules, insurance claims processing, and healthcare compliance standards for commercial and government payers. </li> </ul> <ul> <li>Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS) to ensure accurate and complete claims submission. </li> </ul> <ul> <li>Proven experience in managing claim denials and appeals related to medical necessity, including working with payers or labs to resolve issues. </li> </ul> <ul> <li>Demonstrated ability to identify claims that meet payer criteria and provide written communication in support of reimbursement. </li> </ul> <ul> <li>Experience utilizing claims data to identify unexpected outcomes and trends, perform root cause analysis, and inform process updates. </li> </ul> <ul> <li>Masters Degree in Genetic Counseling or similar clinical degree with demonstrated experience in billing operations and medical necessity rules.  </li> </ul> <ul> <li>Excellent communication, organizational, and problem-solving skills. </li> </ul> <ul> <li>High level of attention to detail and the ability to work under tight deadlines in a fast-paced environment. </li> </ul> <ul> <li>Experience in a leadership/supervisory role preferred but not required. </li> </ul> <ul> <li>Experience with claims management software and data analytics tools. </li> </ul>    Physical Demands  <ul> <li>Ability to stand and sit for extended periods. </li> </ul> Work Environment   <ul> <li>The role may require occasional travel about 10%. </li> </ul> #LI-REMOTE<div><div><div>Pay Transparency, Budgeted Range</div><div>$145,000—$160,000 USD</div></div></div><div>~ 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 <ul> <li>High-quality testing: Our laboratory is CLIA certified and CAP accredited and most of our tests are also New York State approved.</li> <li>Advanced detection: By interrogating genes for complex variants, we can identify the underlying causes of conditions that may otherwise be missed.</li> </ul> CLINICAL EXPERTISE <ul> <li>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.</li> <li>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.</li> <li>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.</li> </ul> Learn more About Us <a href="https://www.genedx.com/about-us" target="_blank">here</a>. 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, youre not just taking on a job—youre 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:   <ul> <li>Be bold in our vision &amp; brave in our execution. </li> <li>Communicate directly, with empathy. </li> <li>Do what we say were going to do.  </li> <li>Be adaptable to change.  </li> <li>Operate with a bias for action.    </li> </ul> Benefits include: <ul> <li>Paid Time Off (PTO)</li> <li>Health, Dental, Vision and Life insurance</li> <li>401k Retirement Savings Plan</li> <li>Employee Discounts</li> <li>Voluntary benefits</li> </ul> GeneDx is an Equal Opportunity Employer. All privacy policy information can be found <a href="https://www.genedx.com/privacy" target="_blank">here</a>.</div>