Product Owner, Claims Editing

Avalon Administrative Services LLC • Tampa, FL

2d • Remote

About The Position

The Product Owner, Claims Editing will identify, design, and support implementation of new automated claim edits that generate incremental value and revenue across Avalon’s claim-editing programs. Initially focused on Routine Test Management (RTM), the role will review existing and emerging policies with Scientific Affairs and Coding & Translation, identify opportunities for additional enforcement, translate those opportunities into configuration-ready rule statements, and model financial impact using claims data and approved AI tools. The analyst will coordinate with Configuration and APEA Development through validation and rollout and support Product and Account Management with training, claim examples, and client adoption. The role may also support Routine Radiology Management (RRM) and Genetic Testing Management (GTM). This position is eligible for remote work, but quarterly travel will be required to Avalon's corporate office located in Tampa, Florida.

Requirements

• Four or more 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 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 the ability to validate AI-assisted work against authoritative sources.
• Strong analytical, documentation, presentation, and cross-functional communication skills.

Nice To Haves

• Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules.
• Experience with laboratory, genetic testing, radiology, or other medical-benefit claims.
• Experience working for a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company.
• Experience with APEA or another claims-editing platform and familiarity with SQL, data-visualization tools, Agile development, or client training.

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 policy requirements into clear, testable rule statements and configuration requirements, including applicable codes, triggers, exclusions, and expected outcomes.
• Evaluate claim-editor capabilities and limitations and recommend new APEA 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 APEA decisioning.
• 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, APEA Development, Account Management, and analytics teams.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level