State Licensed Genetic Counselor

Job Summary

A company is looking for a Clinical Billing Integrity Lead Analyst to ensure compliance with medical necessity rules and payer requirements for claims and prior authorization requests.

Key Responsibilities

• Lead clinical integrity efforts to ensure adherence to medical necessity rules and payer-specific requirements
• Create clinical materials including letters of medical necessity and appeal templates
• Review prior authorization and claims denials for compliance, identifying issues in clinical documentation and coding

Required Qualifications, Training, and Education

• Master's Degree in Genetic Counseling or related field
• Minimum of 3 years of experience, preferably in lab and/or payer settings
• Experience in genetic and molecular billing operations and medical necessity criteria
• Extensive knowledge of clinical documentation and medical coding (CPT, ICD-10, HCPCS)
• Experience with Medicare, Medicaid, and Commercial plans preferred