Appeals Specialist

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. 

The Appeals Specialist is responsible for reviewing denied claims, identifying root causes, and submitting well-documented appeals to maximize reimbursement for specialized laboratory services. This role requires expertise in insurance and government payors, healthcare regulations, and denial resolution. The Appeals Specialist will analyze denial trends, report findings to management, and collaborate with internal teams to improve appeal success rates.

Job Responsibilities

• Review and analyze denied claims to determine the basis for denial and assess appeal potential.
• Communicate with healthcare providers and insurance representatives to gather necessary documentation for appeals.
• Ensure all payor required documentation is submitted with each appeal and tracked in billing system.
• Monitor and follow up on submitted appeals to ensure timely resolution.
• Apply healthcare regulations, payor policies, and coding guidelines to maintain compliance in the appeals process.
• Identify and analyze denial trends, recommending process improvements to reduce future denials.
• Research payor-specific appeal processes to ensure proper steps are followed.
• Collaborate with clinical teams, market access and insurances representatives to resolve appeals issues.

• Perform additional responsibilities as assigned while demonstrating company leadership attributes and supporting of the Mission and Values of the company.

Ideal Candidate

• 3-5 years of experience in laboratory billing appeals.
• Strong understanding of insurance policies, healthcare regulations, medical terminology, and coding.
• Expertise in appeals process for major insurance plans, Medicaid, and Managed Medicaid.
• Ability to manage multiple tasks and prioritize effectively.
• Knowledge of industry regulations, including HIPAA.
• Experience with Xifin is a plus.
• Exceptional attention to detail and organizational abilities.
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook, and Teams) for reporting and documentation.
• Ability to support EST hours.

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