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Clinical Policy, Government Programs Specialist
Avalon Healthcare SolutionsCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicare coverage policy, including NCDs, LCDs, and MAC jurisdictions, while effectively translating regulatory requirements into operational practices. Proficient in claims editing, payment integrity, and coding/auditing with strong analytical skills to support client-specific policy reviews.
Highest-signal resume keywords
Nurse Practitioner LicenseCPT/HCPCS Coding KnowledgeClaims Editing ExperienceAdvanced Excel SkillsRegulatory Research Skills
Tech Stack
Tools & technologiesAbout the role
Key responsibilities & impact- Review monthly NCD/LCD change reports and vendor-supplied extracts to confirm exclusions are accurately reflected in system configuration
- Verify CPT/HCPCS exclusions against client enforcement approaches and MAC jurisdiction rules
- Document completed configuration updates in the agreed repository
- Escalate configuration discrepancies and track them to resolution
- Perform monthly client-specific policy delta reviews and flag required updates
- Support transparency deliverables listing code changes, applicable MACs, and CMS NCD/LCD references
- Compare change reports against client code lists to identify relevant changes
- Maintain and update State Medicaid grids and the state requirements library
- Review enacted legislation for impact on laboratory policies and operations
- Identify conflicts between base policies and state Medicaid requirements and support reconciliation discussions
- Research requirements for new states entering scope
- Serve as primary contact for client regulatory questions through JIRA LPM/ACS tickets
- Engage Clinical MD SMEs and Legal/Government Affairs as needed
- Prepare tailored, client-friendly responses excluding internal-only information
- Support Government Programs enforcement presentations during sales and implementation
- Answer Government Programs questions during policy reconciliation
- Assess client state mandate requests against mandate language and translation documents
- Recommend whether policy variances should be considered
- Document SOPs, define ownership, and strengthen controls and monitoring
- Evaluate AI-assisted approaches for research and regulatory review
- Support commercial mandates grid development and improvements to the client support approach
Requirements
What you’ll need- Minimum 7 years of relevant work experience
- 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, including NCDs, LCDs, and MAC jurisdictions
- Understanding of Medicaid program structure
- Strong research skills and ability to translate regulatory and legislative text into operational impact
- Advanced Excel skills, including lookups, large data sets, and delta/comparison analysis
- Excellent written and verbal communication for non-clinical client audiences
- Sound judgment regarding the boundary between advisory support and legal advice
- Experience with laboratory services, molecular diagnostics, or genetic testing policy preferred
- Experience with a claim-editing or payment integrity platform preferred
- Direct health plan client-facing experience preferred
- Familiarity with JIRA, SharePoint, and SOP/policy documentation tools preferred
- Experience with SQL or data validation tools preferred
- Prior quality assurance or audit experience preferred
- Attention to detail and strong control mindset
- Comfort with ambiguity and building processes where none exist
- Ability to collaborate across Operations, Legal, Product, and Clinical SMEs
- Diplomacy with clients, especially where positions differ
Benefits
Comp & perks- Remote work eligibility
- Travel to the corporate office in Tampa, Florida or other locations
- Equal Opportunity Employer - Vet/Disability
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
CPT CodingHCPCS CodingICD-10 CodingClaims EditingPayment IntegrityUtilization ReviewData ValidationDelta AnalysisPolicy DocumentationRegulatory Compliance
Soft Skills
Excellent CommunicationAttention to DetailSound JudgmentCollaborationDiplomacy
Tools & Technologies
JIRASharePointSOP Documentation ToolsPayment Integrity PlatformsSQL
Certifications & Qualifications
Nurse Practitioner LicenseCPCCCSCPC-P
Industry Keywords
MedicareMedicaidLaboratory ServicesMolecular DiagnosticsGenetic TestingHealth Plan OperationsLegislative ImpactClient-Facing ExperienceQuality AssuranceAudit Experience