Product Owner – Claims Editing

This is a fully remote position, open to applicants in Florida.

📋 Description

• Manage a prioritized pipeline of opportunities to improve existing policies and create new claim edits.

• Examine policies, coding guidelines, regulatory updates, and emerging publications in collaboration with Scientific Affairs and Coding & Translation to pinpoint enforcement opportunities.

• Convert approved policy requirements into concise, testable rule statements and configuration requirements, which include relevant codes, triggers, exclusions, and anticipated outcomes.

• Assess claim-editor capabilities and limitations, and propose new APEA edit functionalities when current capabilities fall short of supporting intended policies.

• Analyze claims data and utilize approved AI and large language model tools to estimate eligible volume, potential savings, incremental revenue, and client impact.

• Create claim examples and test scenarios, facilitate handoff to Configuration, and confirm expected APEA decision-making.

• Assist in the rollout of new edits by developing training materials, walkthroughs, FAQs, and decision-making examples for Product, Account Management, and clients.

• Track implemented edits and suggest modifications that enhance decision accuracy, financial performance, or client adoption.

• Act as the primary liaison between Product, Scientific Affairs, Coding & Translation, Configuration, APEA Development, Account Management, and analytics teams.

• May assist with Routine Radiology Management and Genetic Testing Management.

⛳️ Requirements

• A minimum of four years of relevant experience in healthcare claims editing, payment integrity, medical coding, reimbursement, medical policy, or claims analytics.

• A Bachelor’s degree in a related field or eight years of directly applicable experience in place of a degree.

• Proficient knowledge of healthcare claims, claims adjudication, medical coding systems, and automated claim-editing concepts.

• Capability to convert medical, coding, or reimbursement policies into clear and testable business rules.

• Proficiency in analyzing claims data and estimating operational and financial impacts using Excel, SQL, business-intelligence tools, or similar techniques.

• Familiarity with generative AI and large language models, along with the ability to validate AI-assisted work against authoritative sources.

• Excellent analytical, documentation, presentation, and cross-functional communication skills.

🏝️ Benefits

• Eligibility for remote work.

• Quarterly travel to Avalon’s corporate office located in Tampa, Florida.

• Equal Opportunity Employer - Vet/Disability.