Clinical Policy & Gov't Programs Specialist

Avalon Administrative Services LLC•Tampa, FL

2d•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 are 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 distinction between subject matter expertise and legal advice. The successful candidate is expected to interpret regulatory and coverage policy and translate it into operational impact, exercise sound judgment, maintain strong controls, and build trusted partnerships across Operations, Legal, Configuration, and Clinical teams. The role 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 of 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.

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.
Attention to detail and a strong control mindset.
Comfort with ambiguity and building processes where none exist.
Ability to collaborate across Operations, Legal, Product, and Clinical SMEs.
Diplomacy with clients, especially when positions differ.

Responsibilities

Review monthly NCD/LCD change reports and vendor-supplied extracts, confirming exclusions are accurately reflected in system configuration.
Verify CPT/HCPCS exclusions against each client’s enforcement approach and applicable MAC jurisdiction rules.
Document confirmation that configuration updates were completed and stored in the agreed repository; escalate discrepancies and track them to resolution.
Perform monthly delta reviews for clients that include NCD/LCD language in their policies and flag required policy updates.
Support monthly transparency deliverables, including change reports identifying codes added or removed and 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 effects 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 point of 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, including building a commercial mandates grid and evolving the consultative approach to client support.