Senior Director, Clinical 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.

Job Summary:

The Sr. Director of Clinical Billing Integrity will lead 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 will oversee the application of payer-specific medical necessity criteria, 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:

• Leadership & Oversight: Lead clinical integrity efforts cross functionally to ensure adherence to medical necessity rules and payer-specific requirements for claims and invoices.
• Payer Medical Necessity: Ensure that all claims are reviewed and meet the medical necessity criteria as defined by insurance companies, government programs (e.g., Medicare, Medicaid), and other third-party payers.
• Claim Review & Auditing: Oversee the review of claims for compliance with medical necessity rules, identifying potential issues or discrepancies in clinical documentation and coding.
• Collaboration with Cross-Functional Clinical Teams: Work closely with clinical teams to ensure that patient care documentation supports medical necessity for services billed, providing feedback and guidance on documentation improvement when needed.
• Regulatory Monitoring: Stay current on changes to payer medical necessity guidelines, policies, and healthcare regulations, ensuring all claims processes and procedures are updated accordingly.
• Claims Denial Management: Analyze payer claim denials related to medical necessity, work with appropriate teams to resolve issues, and implement corrective actions to reduce future denials and improve success of appeals
• Training & Education: Provide training and guidance to relevant internal teams on payer medical necessity requirements, claims standards, and best practices for documentation and coding.
• Data Analysis & Reporting: Track and analyze trends in claim denials related to medical necessity, prepare reports for senior management, and recommend process improvements to optimize claims acceptance.
• Policy & Procedure Development: Develop and update claims policies and procedures to reflect payer medical necessity rules, healthcare regulations, and industry best practices.
• Risk Management: Identify and address potential risks related to medical necessity requirements, recommending solutions to mitigate financial or reputational risks to the organization.

People Manager:

• Leads a small team of credentialing and payor specialists

Education, Experience, Skills:

• Master's Degree in Genetic Counseling or similar clinical degree with demonstrated experience in billing operations and medical necessity rules.
• Advanced certifications/degrees in coding, healthcare administration, etc. are highly preferred but not required.
• A minimum of 8 years of experience with a lab or payer claims management related to medical necessity rules, with at least 2 years in a leadership or supervisory role.
• 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 claims denials and appeals related to medical necessity, including working with payers or labs to resolve issues.
• Excellent communication, organizational, and problem-solving skills.
• Strong leadership capabilities with the ability to manage and motivate teams to meet organizational goals.
• High level of attention to detail and the ability to work under tight deadlines in a fast-paced environment.
• Experience with claims management software and data analytics tools.

CERTIFICATES, LICENSES, REGISTRATIONS

• Advanced certifications/degrees in coding, healthcare administration, etc. are highly preferred but not required.

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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

• High-quality testing: Our laboratory is CLIA certified and CAP accredited and most of our tests are also New York State approved.
• Advanced detection: By interrogating genes for complex variants, we can identify the underlying causes of conditions that may otherwise be missed.

CLINICAL EXPERTISE

• 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.
• 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.
• 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.

Learn more About Us here.

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, you're not just taking on a job—you're 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:  

• Be bold in our vision & brave in our execution. 
• Communicate directly, with empathy. 
• Do what we say we're going to do.  
• Be adaptable to change.  
• Operate with a bias for action.    

Benefits include:

• Paid Time Off (PTO)
• Health, Dental, Vision and Life insurance
• 401k Retirement Savings Plan
• Employee Discounts
• Voluntary benefits

GeneDx is an Equal Opportunity Employer.

All privacy policy information can be found here.