Payment Integrity Specialist
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AI Summary
Summary
The Payment Integrity Specialist plays a critical role in ensuring accurate reimbursement and regulatory compliance across payer relationships. This position is responsible for monitoring audits and refund requests, auditing payments against payer contracts, and ensuring adherence to Most Favored Nation (MFN) laws. The specialist will collaborate cross-functionally with billing, appeals, finance, and compliance teams to identify discrepancies, mitigate risks, and optimize revenue integrity.
Job Responsibilities
Audit Oversight
- 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.
Refund and Payment Reconciliation
- 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.
Contract Compliance
- 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.
Regulatory Adherence
- 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.
Cross-Functional Collaboration
- 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.
Education, Experience, and Skills
- 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.
#LI-REMOTE
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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.
A culture that plays to win, because patients are counting on us
At GeneDx, we're driven by urgency and purpose: helping patients get diagnosed earlier. Our mission, to empower everyone to live their healthiest life through genomics, drives our team to make a tangible impact each day – and shapes our culture where high standards, strong teamwork, and meaningful ownership are the norm. We act with intention, support one another, and deliver work we're proud to put our names on.
Here’s what you can expect day to day:
1. Play like a champion (step up, redefine what’s possible, own it)
We bring energy, focus, and a bias for action. We step up, take initiative, and deliver on our commitments – with quality, speed, and care.
We push past the obvious. We challenge assumptions, raise the bar, and make thoughtful, decisive calls — choosing progress over perfection.
We stay curious, ask questions, and share direct feedback with respect. We adapt quickly and keep learning through collaboration and continuous improvement.
If you’re motivated by meaningful work, a fast-moving environment, and teammates who care deeply about outcomes, you’ll thrive at GeneDx.
Benefits include:
- Paid Time Off (PTO)
- Health, Dental, Vision and Life insurance
- 401k Retirement Savings Plan
- Employee Stock Purchase Plan
- Employee Discounts
- Voluntary benefits
- Programs for parents and parents-to-be
- We provide expert support for family planning, pregnancy, and postpartum care, including up to 22 weeks of fully paid parental leave (U.S.) and up to $25K annually for fertility, adoption, or surrogacy.
GeneDx is an Equal Opportunity Employer.
All privacy policy information can be found here.
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