Quality Improvement Specialist

Avalon Administrative Services LLC • Tampa, FL

3d • Remote

About The Position

The Quality Improvement Specialist facilitates quality improvement activities and measurement methods aligned with organizational priorities. The role collaborates with functional areas to understand and alleviate obstacles, and monitors performance through the Quality Improvement Committee. The position is eligible for remote work, with quarterly travel to Avalon’s corporate office in Tampa, Florida required.

The specialist manages quality audits involving claims data analysis, recommendations, implementation, and evaluation; monitors metrics and leads root-cause analysis and improvement actions; and establishes and evaluates the annual Quality Improvement Work Plan. The role also supports committee operations, health plan delegation oversight, internal auditing, and annual review and revision of QI/UM operational policies. Other duties may be assigned by the Manager.

Requirements

• 3–5 years of health care quality improvement experience in a managed care or health care services vendor relationship setting.
• Bachelor’s degree or equivalent experience.
• Certified Professional Coder (CPC) and/or Certified Coding Specialist (CCS), and/or Certified Professional Medical Auditor (CPMA) certification.
• Working knowledge of medical policies and medical coding.
• Strong knowledge of health plan claims, medical billing, and medical coding.
• Expert written and oral communication skills.
• Expert computer skills, including Microsoft Office Suite; Excel is required.
• Strong understanding of health insurance claims and terminology.
• Strong communication, delivery, and presentation skills.
• Strong understanding of laboratory billing and reimbursement practices.
• High attention to detail and documentation.
• Clinical experience and background in ICD-10, CPT, and HCPCS coding principles.
• Exceptional interpersonal skills and demonstrated ability to work independently and as part of a team.
• Strong organizational skills.

Nice To Haves

• Experience with Centers for Medicare & Medicaid Services (CMS) and industry-standard billing, compliance, and reimbursement methodologies.
• Laboratory or genetic testing experience or familiarity.
• Familiarity with commercial payor medical policies.
• Knowledge of and experience with laboratory medical coding rules and regulations, compliance, reimbursement, and bundling issues.
• Experience with data analysis tools such as SQL, PowerBI, and JIRA.
• Certification in healthcare quality.
• Background or education in biology, chemistry, medicine, or nursing.

Responsibilities

• Manage and monitor quality audits, including receiving and analyzing claims data, developing improvement recommendations, implementing plans, and evaluating results.
• Perform quality audits using claims-data analytics and identify inconsistent results.
• Deliver quality-audit findings and recommendations on monthly and quarterly cadences.
• Collaborate with Medical Policy, Configuration, Policy and Enforcement, and Coding and Translation departments to accurately reflect medical and claims payment policies.
• Monitor required QI Work Plan metric trends, identify variation, convene teams for root-cause analysis, and institute actions to achieve performance goals.
• Establish and maintain the annual QI Work Plan, defining priorities and metrics, updating it with new information, and conducting an annual evaluation.
• Set agendas and create Quality Improvement Committee meeting materials, support desired meeting outcomes, and ensure committee activities are recorded.
• Perform departmental functions related to client health plan delegation oversight, internal auditing, and annual QI/UM operational policy review and revision.
• Perform other duties as assigned by the Manager.

What This Job Offers

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