Clinical Policy & Gov't Programs Specialist

Avalon Administrative Services•Tampa, FL

14h•Remote

About The Position

Avalon Healthcare Solutions is seeking a detail-oriented, clinically grounded specialist to support regulatory and compliance functions, including NCD/LCD enforcement validation, state Medicaid alignment, and client regulatory advisory support. The role helps ensure claim-edit configurations remain accurate, timely, and aligned with Medicare and state Medicaid requirements. It also provides health plan clients with clear guidance on Avalon’s policies and enforcement approaches while maintaining the boundary between subject matter expertise and legal advice. The specialist will interpret regulatory and coverage policies and translate them into operational impact. The role calls for sound judgment, a strong control mindset, and trusted collaboration across Operations, Legal, Configuration, and Clinical teams. The position is eligible for remote work, with required travel to the corporate office in Tampa, Florida, or other locations.

Requirements

At least 7 years of relevant work experience.
Bachelor of Science in Nursing or Master of Science in Nursing.
Previous or active, unrestricted U.S. Nurse Practitioner license.
Professional coding credential (e.g., CPC, CCS, CPC-P) or equivalent experience.
At least 3 years of experience in claims editing, payment integrity, coding/auditing, utilization review, or health plan operations.
Working knowledge of CPT, HCPCS, and ICD-10 coding.
Strong understanding of Medicare coverage policy, including NCDs, LCDs, and MAC jurisdictions, and Medicaid program structure.
Strong research skills, including the ability to interpret regulatory and legislative text and translate it into operational impact.
Advanced Excel skills, including lookups, large data sets, and delta/comparison analysis.
Excellent written and verbal communication, including the ability to write clearly for non-clinical client audiences.
Sound judgment about where advisory support ends and legal advice begins.
Attention to detail and a strong control mindset.
Ability to collaborate across Operations, Legal, Product, and Clinical SMEs.
Diplomacy with clients, including when positions differ.
Comfort with ambiguity and building processes where none exist.

Nice To Haves

Experience with laboratory services, molecular diagnostics, or genetic testing policy.
Experience with a claim-editing or payment integrity platform.
Direct health plan client-facing experience.
Familiarity with JIRA, SharePoint, and SOP/policy documentation tools.
Experience with SQL or data validation tools.
Prior work in quality assurance or audit functions.

Responsibilities

Review monthly NCD/LCD change reports and vendor-supplied extracts, confirming that exclusions are accurately reflected in system configuration.
Verify CPT/HCPCS exclusions against each client’s enforcement approach and applicable MAC jurisdiction rules.
Document confirmation of completed configuration updates in the agreed repository, and escalate and track discrepancies through resolution.
Conduct monthly policy delta reviews for clients whose policies include NCD/LCD language, and flag required updates.
Support monthly transparency deliverables, including change reports listing codes added or removed with applicable MAC and CMS NCD/LCD references.
Compare change reports with each client’s applicable code list so clients receive only relevant changes.
Maintain and update State Medicaid grids and the state requirements library.
Review enacted legislation monthly for its impact on laboratory policies and operations, updating grids as needed.
Identify potential conflicts between base policies and state Medicaid requirements and support policy reconciliation discussions.
Research requirements for new states as they come into scope.
Serve as the primary contact for client regulatory questions submitted through JIRA LPM/ACS tickets, engaging Clinical MD SMEs and Legal/Government Affairs as needed.
Prepare tailored, client-friendly responses that exclude internal-only information.
Support the Government Programs enforcement presentation during sales and implementation and answer GovPro questions during policy reconciliation.
Review exact state mandate language against translation documents and recommend whether a variance should be considered.
Document SOPs, define ownership, and strengthen controls and monitoring.
Evaluate AI-assisted approaches for research and regulatory review.
Support special projects, such as building a commercial mandates grid and evolving the consultative approach to client support.