Billing - Pre-Claims Operations Manager

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. 

Summary 

The Pre-Claims Operations Manager is responsible for overseeing and managing the processes that occur before a claim is filed. This includes leading the team responsible for prior-authorization activities, managing policy documentation, and gathering relevant information to conduct periodic audits against policy. The role ensures efficiency and accuracy prior to filing a claim

Job Responsibilities

• Leadership and Team Management: Lead, coach, and develop a team of prior-authorization specialists, ensuring high levels of performance and motivation. Monitor workloads, set priorities, and ensure timely completion of tasks. 
• Claims Preparation and Submission: Ensure that all claims are prepared and ready for submission to insurance carriers, including reviewing for accuracy and completeness before sending. Resolve any discrepancies or errors identified during the submission process. 
• Process Optimization: Work with the Associate Director of Billing to Identify opportunities to streamline and improve pre-claims operations. Develop and implement process enhancements to increase efficiency, reduce errors, and improve overall service quality. 
• Claims Validation: Oversee the initial review of policyholder inquiries, ensuring accuracy before claim submission.  
• Collaboration: Work closely with our third-party vendors and internal departments, such as customer service, to ensure smooth handoffs and the effective resolution of issues that may arise. 
• Issue Resolution: Act as the point of contact for resolving issues related to prior-authorizations, billing discrepancies, or denied prior-authorizations.  
• Regulatory Compliance: Ensure that all prior-authorization and billing practices comply with federal, state, and local regulations, as well as insurance company guidelines and laboratory policies. 
• Training and Development: Develop training programs and materials for new hires and existing team members. Conduct ongoing training to improve knowledge of pre-claims processes, regulatory changes, and customer service skills. 
• Reporting and Metrics: Provide regular reports to leadership regarding the status of prior-authorization requests, billing accuracy, claim rejections, and other relevant metrics. Ensure timely reporting of key performance indicators (KPIs). 

People Manager

• Yes

Education, Experience, and Skills

• Education: Bachelor’s degree in Business Administration, Health Administration, or a related field (or equivalent work experience).

• Experience:
  • Minimum of 5 years of experience in billing, coding, or healthcare operations, with at least 2 years in a supervisory or management role.
  • In-depth knowledge of prior-authorization processes and insurance billing procedures.
  • Experience with laboratory billing systems, healthcare insurance claim submission, and payment processes.
  • Prior experience with Xifin and careviso is highly desirable.

• Skills:
  • Strong leadership and team management skills with the ability to motivate and develop employees.
  • Excellent communication skills, both verbal and written, with a focus on customer service and collaboration.
  • Strong analytical and problem-solving skills, with the ability to identify issues and create actionable solutions.
  • Proficiency in Microsoft Office Suite and claims management software.
  • Familiarity with regulatory requirements related to healthcare billing, HIPAA compliance, and insurance payer policies.
  • Understanding of insurance company processes, including prior-authorization and claims review processes.

Certificates, Licenses, Registrations

• • Certification in medical billing or coding (e.g., Certified Professional Coder (CPC), Certified Coding Specialist (CCS)).