Payment Integrity Specialist

Responsibilities

• 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
• 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
• Validate that payments align with negotiated payer contracts and MFN provisions
• Collaborate with legal, contracting, appeals, and market access teams
• Stay current on federal and state regulations impacting payment integrity
• Assist in preparing responses to regulatory inquiries and payer audits

Requirements

• Bachelor’s degree in healthcare administration, finance, or related field
• 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 and analytical thinking
• Excellent communication and documentation abilities

Preferred Qualifications

• CPCS or similar certification

About the Company

GeneDx is driven by a mission to empower everyone to live their healthiest life through genomics, helping patients get diagnosed earlier through advanced genomic testing.