Prior Authorization Specialist

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 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. 
• Other duties may be assigned. 

People Manager 

• No 

 Education, Experience, and Skills 

• High school diploma preferred. 

• 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. 

Certificates, Licenses, Registrations 

• None 

Work Environment 

This is a fully remote position. The employee will work from a home office or other suitable remote location with reliable high-speed internet access. Work is performed in a climate-controlled environment using standard office equipment including computer, phone, and video conferencing tools. Your standard work schedule and hours will be established in collaboration with your leader and may be adjusted to align with evolving business needs. 

Physical Demands 

This is a sedentary role requiring prolonged periods of sitting while working at a computer. Physical demands include: 

• Sitting for extended periods (up to 8 hours per day)