Prior Authorization Specialist

GeneDx is a patient-centric health information company that delivers personalized and actionable health insights that inform diagnosis, guide treatment and improve drug discovery. The company is transforming healthcare through its industry-leading exome and genome testing and interpretation, fueled by one of the world’s largest, rare disease data sets.  GeneDx is uniquely positioned to accelerate the use of genomic and large-scale clinical information to enable precision medicine as the standard of care.

We are seeking a add a Prior Authorization Specialist to our team. The Prior Authorization specialist will work closely with the Prior Authorization Manager who is responsible for all aspects of the prior and retro authorization process. This role also involves responding to email inquiries, filing appeals for denied prior authorizations, ensuring timely resolution, and supporting reimbursement efforts. The ideal candidate will have a strong understanding of the prior authorization process, healthcare insurance billing, medical terminology, and appeals process.

Job Responsibilities

• Actively review and resolve Prior Authorization inquires in SalesForce
• Research accounts that require appeals for prior authorization denials
• Prepare and submit appeals to insurance companies, including the compilation of necessary medical records, documentation, and justification.
• Review and resolve rejected authorizations.
• Communicate effectively with healthcare providers and insurance companies to facilitate peer to peer review.
• Submit and track prior authorization requests using appropriate systems and tools.
• Ensure all required documentation is complete and accurate to avoid delays in authorization.
• Track appeal outcomes and follow up on unresolved cases to ensure successful resolution.
• Collaborate closely with clinical teams, billing department, market access and insurance representatives to resolve authorization issues.
• Provide regular updates to management on the status of authorizations and appeals.
• Stay informed of changes in insurance guidelines and payer requirements.
• Communicate effectively with internal and external stakeholders.
• The job may have added responsibilities as assigned. All job duties must be performed in a manner that demonstrates the company Leadership Attributes and support of the Mission & Values of the company.

Ideal Candidate

• 3-5 years of experience in healthcare billing experience, with a focus on prior authorizations and appeals.
• Strong understanding of insurance policies, medical terminology, and coding.
• Be well-versed in insurance authorization and verification process for major health plans.
• Strong communication and interpersonal skills, with the ability to work effectively in a team environment.
• Experience using Google Apps, Mac OS X, and CRM applications.

• Understanding of industry-specific policies, such as HIPAA regulations for health care.
• Xifin, SalesForce and careviso experience a plus

• Can support EST hours.
• Exceptional attention to detail and organizational abilities.