Job Description

Job Description

About Avalon Healthcare Solutions:

Avalon Healthcare Solutions 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 nationwide, the company covers over 44+ million lives and delivers 10-20% proven outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Program 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 costs. 

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. 

Avalon has years of expertise in managing lab benefits and now is leveraging digitized lab results to drive quality clinical outcomes and proven savings. When you look at how we bring this to life, we offer Lab Insights solutions that work together to arm you with critical lab-driven insights to accelerate your value-driven care success. This is the first-of-its-kind suite of solutions to help you achieve the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per-member cost of healthcare.

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

About the Policy Coding and Enforcement Analyst:

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 will be required to Avalon's corporate office located in Tampa, Florida.

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’s degree in biology, chemistry, medicine, nursing, medical technology, or related field, or equivalent related work experience
• 5 years minimum work experience
• 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 – Preferred Qualifications:

• 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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PId57597c3e0ba-25405-37691711

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