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 technology and initiatives for summarization of clinical information for both pre-and post-test teams.
Provide insight into new and emerging use cases for exome and genome sequencing.
Provide feedback for Market Access on payor specific gaps in coverage and/or misalignment to industry standards.
Analyze data trends, using a variety of data visualization tools (e.g. PowerBI, Tableau, Smartsheets) to find new opportunities for targeted expansion of clinical billing integrity team efforts.

Master's Degree in Genetic Counseling or related field
Minimum of 3 years of experience, lab and/or payer experience preferred.
Demonstrated experience in genetic and molecular billing operations and medical necessity criteria.
Extensive experience with clinical documentation and medical coding (CPT, ICD-10, HCPCS)
Experience with Medicare, Medicaid, and Commercial plans preferred.
Excellent communication, organizational, and problem-solving skills.

Clinical Billing Integrity Lead Analyst

Key skills