[Remote] Clinical Policy & Gov't Programs Specialist

Note: The job is a remote job and is open to candidates in USA. Avalon Healthcare Solutions is seeking a Clinical Policy & Government Programs Specialist to support regulatory and compliance functions and ensure claim-edit configurations align with Medicare and state Medicaid requirements. The role validates NCD/LCD enforcement, maintains state Medicaid requirements, and provides client guidance while partnering with Operations, Legal, Configuration, and Clinical teams.

Responsibilities

• Review the monthly NCD/LCD change report and the vendor-supplied extract, and confirm exclusions are accurately reflected in system configuration
• Verify CPT/HCPCS exclusions follow each client's enforcement approach (Cost Savings or CPT Code Match) and MAC jurisdiction rules
• Maintain documented confirmation that configuration updates were completed, stored in the agreed repository
• Escalate discrepancies to Configuration and Operations and track them to resolution
• Perform monthly delta reviews for clients that embed NCD/LCD language directly in their policies, and flag required policy updates
• Support monthly transparency deliverables, such as change reports listing codes added or removed with the applicable MAC and CMS NCD/LCD reference
• Compare change reports against each client's applicable code list so clients see only relevant changes
• Maintain and update State Medicaid grids and the state requirements library
• Review enacted legislation monthly for impact on laboratory policies and operations, and update grids when needed
• Identify potential conflicts between base policies and state Medicaid requirements and support policy reconciliation discussions
• Build out research for new states as they come into scope
• Serve as the primary point person for client regulatory questions (JIRA LPM/ACS tickets), engaging Clinical MD SMEs and Legal/Government Affairs as needed
• Prepare client-friendly, tailored responses that exclude internal-only information
• Support the Government Programs enforcement presentation during sales and implementation and answer GovPro questions during policy reconciliation
• Assess client state mandate requests by reviewing the exact mandate language against the translation document 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 projects such as building commercial mandates grid or evolving consultative approach to client support

Skills

• Minimum years of relevant work experience: 7 years
• Minimum education: Bachelor of Science in Nursing / Master of Science in Nursing
• Previous or Active, unrestricted U.S. license as a Nurse Practitioner (NP)
• Professional coding credential (e.g., CPC, CCS, CPC-P) or equivalent experience
• 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 (NCDs, LCDs, MAC jurisdictions) and Medicaid program structure
• Strong research skills, with the ability to read regulatory and legislative text and translate it into operational impact
• Advanced Excel skills (lookups, large data sets, delta/comparison analysis)
• Excellent written and verbal communication, including writing clearly for non-clinical client audiences
• Sound judgment on where advisory support ends and legal advice begins
• 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 process where none exists
• Collaboration across Operations, Legal, Product, and Clinical SMEs
• Diplomacy with clients, especially where positions differ

Benefits

• Eligible for remote work, but travel to the corporate office in Tampa, Florida or other locations is required.

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