Product Owner, Claims Editing

Job not on LinkedIn

🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

✅ Product Manager

👻 Ghost score 10%

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Avalon Healthcare Solutions

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2013

🏥 Healthcare

☁️ SaaS

⚕️ Healthcare Insurance

Healthcare • SaaS • Healthcare Insurance

Avalon Healthcare Solutions is a healthcare technology company that provides a Diagnostic Intelligence platform and benefit-management services to health plans, labs, and providers. Using evidence-based policies, real-time test decisioning, curated lab networks, automated workflows, and analytics, Avalon manages and optimizes diagnostic testing — including genetic testing, oncology (liquid biopsy), cardiometabolic, and routine labs — to reduce waste, speed care, and improve outcomes. The company focuses on lab benefit management, precision genetic test management, and analytics to deliver measurable savings and operational oversight for payers and diagnostic partners.

📋 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 • Initially focus on Routine Test Management (RTM), with potential support for Routine Radiology Management (RRM) and Genetic Testing Management (GTM)

🎯 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 the ability to validate AI-assisted work against authoritative sources • Strong analytical, documentation, presentation, and cross-functional communication skills • Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules preferred • Experience with laboratory, genetic testing, radiology, or other medical-benefit claims preferred • Experience working for a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company preferred • Experience with APEA or another claims-editing platform and familiarity with SQL, data-visualization tools, Agile development, or client training preferred

🏖️ Benefits

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