Product Owner, Claims Editing

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

📋 Description

• Manage a prioritized list of opportunities to improve current policies and create new claim edits.

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

• Convert approved policy requirements into precise, testable rule statements and configuration specifications, including applicable codes, triggers, exclusions, and anticipated results.

• Assess claim-editor capabilities and limitations, recommending new APEA edit functionalities when existing features fail to meet policy goals.

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

• Create claim examples and testing scenarios, facilitate the transition to Configuration, and confirm expected APEA decisioning.

• Assist in the implementation of new edits by developing training materials, walkthroughs, FAQs, and decisioning examples for Product, Account Management, and clients.

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

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

• Initially concentrate on Routine Test Management (RTM), with potential assistance for Routine Radiology Management (RRM) and Genetic Testing Management (GTM).

⛳️ Requirements

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

• Bachelor's degree in a related field or eight or more years of directly relevant experience in place of a degree.

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

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

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

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

• Strong skills in analysis, documentation, presentation, and cross-functional communication.

• Direct experience in developing, testing, or implementing automated claim edits or payment-integrity rules is preferred.

• Experience with laboratory, genetic testing, radiology, or other medical-benefit claims is preferred.

• Background in a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company is preferred.

• Familiarity with APEA or another claims-editing platform, as well as knowledge of SQL, data-visualization tools, Agile development, or client training is preferred.

🏝️ Benefits

• Eligibility for remote work.

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

• Equal Opportunity Employer - Vet/Disability.