Payment Integrity Specialist

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GeneDx

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

At GeneDx, we believe that everyone deserves personalized, targeted medical care—and that it all begins with a genetic diagnosis. Fueled by one of the world’s largest rare disease data sets, our industry-leading exome and genome tests translate complex genomic data into clinical answers that unlock personalized health plans, accelerate drug discovery, and improve health system efficiencies. It all starts with a single test.

📋 Description

• Monitor internal and external audits related to claims, payments, and refunds • Conduct periodic audits of payer contracts and payment activity to ensure compliance with MFN laws and contractual terms • Identify and escalate discrepancies in payment rates, coding, and authorization processes • Review and process refund requests from payers and patients • Ensure timely and accurate posting of payments and resolution of denials • Maintain detailed records of transactions and audit findings • Validate that payments align with negotiated payer contracts and MFN provisions • Collaborate with legal and contracting teams to interpret and apply MFN rules • Support payer configuration reviews and contract audits • Stay current on federal and state regulations impacting payment integrity, including MFN laws • Ensure audit processes and documentation meet compliance standards • Assist in preparing responses to regulatory inquiries and payer audits • Partner with appeals, credentialing, and market access teams to resolve payment issues • Provide feedback and process improvement recommendations to operational teams • Participate in payer meetings and internal workgroups to enhance audit and payment workflows

🎯 Requirements

• Bachelor’s degree in healthcare administration, finance, or related field (or equivalent experience) • 3–5 years of experience in medical billing, payment integrity, or payer contract auditing • Strong understanding of MFN laws, payer policies, and healthcare reimbursement models • Proficiency in claims management systems and data analytics tools • Exceptional attention to detail, analytical thinking, and problem-solving skills • Excellent communication and documentation abilities • CPCS or similar certification preferred

🏖️ Benefits

• Competitive compensation and benefits • Health insurance • Paid time off • Flexible work arrangements • Professional development opportunities