Appeals 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. 

The Appeals Specialist is responsible for reviewing denied claims, identifying root causes, and submitting well-documented appeals to maximize reimbursement for specialized laboratory services. This role requires expertise in insurance and government payors, healthcare regulations, and denial resolution. The Appeals Specialist will analyze denial trends, report findings to management, and collaborate with internal teams to improve appeal success rates. 

Job Responsibilities 

• Review and analyze denied claims to determine the basis for denial and assess appeal potential. 

• Communicate with healthcare providers and insurance representatives to gather necessary documentation for appeals. 

• Ensure all payor required documentation is submitted with each appeal and tracked in the billing system. 

• Monitor and follow up on submitted appeals to ensure timely resolution. 

• Apply healthcare regulations, payor policies, and coding guidelines to maintain compliance in the appeals process. 

• Identify and analyze denial trends, recommending process improvements to reduce future denials.  

• Research payor-specific appeal processes to ensure proper steps are followed.  

• Collaborate with clinical teams, market access and insurances representatives to resolve appeals issues. 

• Perform additional responsibilities as assigned while demonstrating company leadership attributes and supporting the Mission and Values of the company.   

People Manger

• No  

Education, Experience, and Skills 

• 3-5 years of experience in laboratory billing appeals. 

• Strong understanding of insurance policies, healthcare regulations, medical terminology, and coding. 

• Expertise in appeals process for major insurance plans, Medicaid, and Managed Medicaid. 

• Ability to manage multiple tasks and prioritize effectively. 

• Knowledge of industry regulations, including HIPAA. 

• Experience with Xifin is a plus. 

• Exceptional attention to detail and organizational abilities. 

• Proficiency in Microsoft Office Suite (Excel, Word, Outlook, and Teams) for reporting and documentation. 

• Ability to support EST hours.  

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) 

• Repetitive use of hands and fingers for typing and mouse operation 

• Visual acuity for reading computer screens and documents 

• Ability to communicate effectively via phone and video calls 

• Occasional lifting of up to 10 pounds (office supplies, equipment) 

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. 
 
Acknowledgements 

The above job description is not intended to be an all-inclusive list of duties and standards of the position.  Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.