Claims Editing Analyst, Genetics

Avalon Healthcare Solutions

. Maintain a prioritized pipeline of opportunities to enhance existing policies and develop new claim edits .

Posted 10/17/2026full-timeTampa • Florida • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims editing and payment integrity, with a strong ability to translate medical policies into actionable business rules. Proficient in analyzing claims data and utilizing AI tools to enhance decision-making and operational efficiency.

Highest-signal resume keywords

Claims EditingMedical CodingClaims AnalyticsExcelSQL

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims EditingMedical CodingClaims AnalyticsPolicy TranslationData AnalysisAutomated Claim EditingFinancial Impact EstimationDocumentationPresentation SkillsAttention to Detail

Soft Skills

Cross-Functional CommunicationAnalytical Skills

Tools & Technologies

Business-Intelligence ToolsGenerative AILarge Language Models

Industry Keywords

Healthcare ClaimsClaims AdjudicationPayment IntegrityMolecular Pathology CodingLaboratory BillingDiagnostic Testing

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

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 clinical and reimbursement policy requirements into clear, testable rule statements and configuration requirements, including applicable codes, triggers, exclusions, and expected outcomes
Evaluate combinations of CPT, HCPCS, PLA, ICD-10-CM, modifiers, place of service, provider and laboratory identifiers, authorization status, and other claim data needed to apply edits accurately
Identify opportunities to automate policy enforcement for nonspecific molecular pathology codes, Tier 2 codes, unlisted codes, panels, and other genetic services
Evaluate claim-editor capabilities and limitations and recommend new edit functionality when needed
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 claim decisions
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 to improve decision accuracy, financial performance, or client adoption
Serve as the primary connection between Product, Scientific Affairs, Coding & Translation, Configuration, Development, Account Management, and analytics teams

Requirements

What you’ll need

3+ years of relevant experience in claims editing, payment integrity, medical coding, medical policy, reimbursement, or claims analytics
Bachelor’s degree in a related field or 8+ years of 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 with close attention to detail
Preferred: Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules
Preferred: Familiarity with genetic and genomic testing, molecular pathology coding, laboratory billing, or the diagnostic testing environment
Preferred: Experience working for a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company
Preferred: Experience developing or maintaining automated prepayment or post payment claim edits in a commercial editing platform or proprietary rules engine
No required certification

Benefits

Comp & perks

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