Job Description

Avalon Healthcare Solutions, headquartered in Tampa, Florida, is the world’s first and only Lab Insights company, bringing together our proven Lab Benefit Management solutions, lab science expertise, digitized lab values, and proprietary analytics to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Working with health plans across the country, the company covers more than 36 million lives and delivers 7-12% outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Platform that captures, digitizes, and analyzes lab results in real time to provide actionable insights for earlier disease detection, ensuring appropriate treatment protocols, and driving down overall cost.

Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.

Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies.

Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.

For more information about Avalon, please visit www.avalonhcs.com.

Avalon Healthcare Solutions is proud to be an equal opportunity employer including disability/veteran. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.

Avalon Healthcare Solutions provides and maintains a drug-free workplace for its employees.

For more about Avalon, please visit our web site at http://www.avalonhcs.com.

About the Policy Coding and Enforcement Analyst position:

The Policy Coding and Enforcement Analyst will work closely with Medical Policy and Configuration Management to ensure proper coding and translation of medical policies into enforcement rules to implement within the automated Avalon claims editor.

This position is eligible for remote work, but quarterly travel to the corporate office in Tampa, Florida will be required quarterly.

Policy Coding and Enforcement Analyst– Essential Functions and Responsibilities:

• Review each Avalon Medical Policy to identify necessary coding and enforcement updates.
• Application of proper ICD-10, CPT, and HCPCS coding to Avalon Medical Policies.
• Develop Avalon Medical Policy enforcement rules, to include rationale for interpretation, supporting evidence, and documentation, from Avalon Medical and Payment Policies.
• Identify and record coding and enforcement changes for each policy.
• Coding and enforcement analysis and research as needed.

Policy Coding and Enforcement Analyst – Minimum Qualifications:

• Bachelor degree or equivalent related work experience
• Biology, chemistry, medicine, nursing, medical technology, or related field of education
• Clinical experience with a background of ICD-10, CPT, and HCPCS coding principles
• Experience with developing claim editing and enforcement rules
• High attention to detail, including proper documentation
• Strong understanding of laboratory billing and reimbursement practices
• Strong verbal and written communication skills with the ability to simply convey complex subject matter
• Independent, capable of decision making with limited information

Policy Coding and Enforcement Analyst – Qualifications Preferred:

• Certified Medical Coder - RHIT, CPC, CCS or similar
• Configuration experience – edit building or testing
• Knowledge of and experience with laboratory medical coding rules and regulations, compliance, and reimbursement
• Experience with Centers for Medicare & Medicaid Services (CMS) and industry standard billing, compliance, and reimbursement methodologies
• Familiarity with commercial payor medical policies
• Familiarity with government programs, such as Medicare and Medicaid
• Experience with data analysis tools

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