Claims Editing Analyst, Genetics

Avalon Administrative Services LLC•Tampa, FL

7h•Remote

About The Position

The Claims Editing Analyst, Genetics Testing Management (GTM) identifies, designs, and supports implementation of automated claim edits that create value and revenue across Avalon’s claim-editing programs. Initially focused on genetic testing management, the analyst reviews existing and emerging policies with Scientific Affairs and Coding & Translation, identifies opportunities for additional enforcement, converts approved requirements into configuration-ready rules, and models financial impact using claims data and approved AI tools. The analyst coordinates with Configuration and Development through validation and rollout and supports Product and Account Management with training, claim examples, and client adoption. This early-career role is intended for a professional with an existing understanding of healthcare claims and experience in claim editing or payment integrity. Success requires careful interpretation of clinical and reimbursement policies, analytical discipline, and the ability to turn written requirements into precise, testable rules. The position is eligible for remote work, with quarterly travel to Avalon’s corporate office in Tampa, Florida.

Requirements

At least 3 years of relevant experience in healthcare claims editing, payment integrity, medical coding, reimbursement, medical policy, claims analytics, or a related field.
Bachelor’s degree in a related field, or at least 8 years of directly applicable experience in lieu of a degree.
Working knowledge of healthcare claims, claims adjudication, medical coding systems, and automated claim-editing concepts.
Demonstrated ability to translate medical, coding, or reimbursement policies into clear and testable business rules.
Ability to analyze claims data and estimate operational and financial impact using Excel, SQL, business-intelligence tools, or similar methods.
Familiarity with generative AI and large language models, and ability to validate AI-assisted work against authoritative sources.
Strong analytical, documentation, presentation, and cross-functional communication skills, with close attention to detail.

Nice To Haves

Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules.
Familiarity with genetic and genomic testing, molecular pathology coding, laboratory billing, or the diagnostic testing environment.
Experience working for a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company.
Experience developing or maintaining automated prepayment or post-payment claim edits in a commercial editing platform or proprietary rules engine.

Responsibilities

Maintain a prioritized pipeline of opportunities to enhance existing policies and develop new claim edits.
Review policies, coding guidance, regulatory updates, and emerging publications with Scientific Affairs and Coding & Translation to identify enforcement opportunities.
Translate approved clinical and reimbursement policy requirements into clear, testable rule statements and configuration requirements, including applicable codes, triggers, exclusions, and expected outcomes.
Evaluate combinations of CPT, HCPCS, PLA, ICD-10-CM, modifiers, place of service, provider and laboratory identifiers, authorization status, and other available claim data needed to apply edits accurately.
Identify opportunities to automate policy enforcement for nonspecific molecular pathology codes, Tier 2 codes, unlisted codes, panels, and other genetic services that may be difficult to identify from a single claim field.
Evaluate claim-editor capabilities and limitations and recommend new edit functionality when existing capabilities cannot support the intended policy.
Analyze claims data and use approved AI and large language model tools to estimate eligible volume, potential savings, incremental revenue, and client impact.
Develop claim examples and test scenarios, coordinate handoff to Configuration, and validate expected claim decisions.
Support rollout of new edits by creating training materials, walkthroughs, FAQs, and decisioning examples for Product, Account Management, and clients.
Monitor implemented edits and recommend changes that improve decision accuracy, financial performance, or client adoption.
Serve as the primary connection between Product, Scientific Affairs, Coding & Translation, Configuration, Development, Account Management, and analytics teams.