Note: The job is a remote job and is open to candidates in USA. Avalon Healthcare Solutions is seeking a Clinical Policy & Government Programs Specialist to support regulatory and compliance functions and ensure claim-edit configurations align with Medicare and state Medicaid requirements. The role validates NCD/LCD enforcement, maintains state Medicaid requirements, and provides client guidance while partnering with Operations, Legal, Configuration, and Clinical teams.
Responsibilities
- Review the monthly NCD/LCD change report and the vendor-supplied extract, and confirm exclusions are accurately reflected in system configuration
- Verify CPT/HCPCS exclusions follow each client's enforcement approach (Cost Savings or CPT Code Match) and MAC jurisdiction rules
- Maintain documented confirmation that configuration updates were completed, stored in the agreed repository
- Escalate discrepancies to Configuration and Operations and track them to resolution
- Perform monthly delta reviews for clients that embed NCD/LCD language directly in their policies, and flag required policy updates
- Support monthly transparency deliverables, such as change reports listing codes added or removed with the applicable MAC and CMS NCD/LCD reference
- Compare change reports against each client's applicable code list so clients see only relevant changes
- Maintain and update State Medicaid grids and the state requirements library
- Review enacted legislation monthly for impact on laboratory policies and operations, and update grids when needed
- Identify potential conflicts between base policies and state Medicaid requirements and support policy reconciliation discussions
- Build out research for new states as they come into scope
- Serve as the primary point person for client regulatory questions (JIRA LPM/ACS tickets), engaging Clinical MD SMEs and Legal/Government Affairs as needed
- Prepare client-friendly, tailored responses that exclude internal-only information
- Support the Government Programs enforcement presentation during sales and implementation and answer GovPro questions during policy reconciliation
- Assess client state mandate requests by reviewing the exact mandate language against the translation document and recommend whether a variance should be considered
- Document SOPs, define ownership, and strengthen controls and monitoring
- Evaluate AI-assisted approaches for research and regulatory review
- Support projects such as building commercial mandates grid or evolving consultative approach to client support
Skills
- Minimum years of relevant work experience: 7 years
- Minimum education: Bachelor of Science in Nursing / Master of Science in Nursing
- Previous or Active, unrestricted U.S. license as a Nurse Practitioner (NP)
- Professional coding credential (e.g., CPC, CCS, CPC-P) or equivalent experience
- 3+ years of experience in claims editing, payment integrity, coding/auditing, utilization review, or health plan operations
- Working knowledge of CPT, HCPCS, and ICD-10 coding
- Strong understanding of Medicare coverage policy (NCDs, LCDs, MAC jurisdictions) and Medicaid program structure
- Strong research skills, with the ability to read regulatory and legislative text and translate it into operational impact
- Advanced Excel skills (lookups, large data sets, delta/comparison analysis)
- Excellent written and verbal communication, including writing clearly for non-clinical client audiences
- Sound judgment on where advisory support ends and legal advice begins
- Experience with laboratory services, molecular diagnostics, or genetic testing policy
- Experience with a claim-editing or payment integrity platform
- Direct health plan client-facing experience
- Familiarity with JIRA, SharePoint, and SOP/policy documentation tools
- Experience with SQL or data validation tools
- Prior work in quality assurance or audit functions
- Attention to detail and a strong control mindset
- Comfort with ambiguity and building process where none exists
- Collaboration across Operations, Legal, Product, and Clinical SMEs
- Diplomacy with clients, especially where positions differ
Benefits
- Eligible for remote work, but travel to the corporate office in Tampa, Florida or other locations is required.
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