Product Owner – Claims Editing

Job not on LinkedIn

🔥 2 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

✅ Product Manager

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Avalon Healthcare Solutions

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2013

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Avalon Healthcare Solutions is a company that provides Diagnostic Intelligence and lab benefit management solutions to health plans, labs, and providers. It offers a platform and services — including genetic test management, routine test and radiology management, curated lab networks, real-time test decisioning, evidence-based policies, and analytics — to reduce unnecessary diagnostic testing, control costs, and improve care quality. Avalon emphasizes science-driven, evidence-based approaches to manage growing diagnostic complexity (particularly genetic testing and oncology), delivering operational workflows and measurable savings for health plans and other healthcare organizations.

📋 Description

• 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 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 • May support Routine Radiology Management and Genetic Testing Management

🎯 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 • 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

🏖️ Benefits

• Remote work eligibility • Quarterly travel to Avalon’s corporate office in Tampa, Florida • Equal Opportunity Employer - Vet/Disability