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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 and Medicaid policy analysis, coding, and compliance, with a strong ability to translate regulatory requirements into operational impacts. Proficient in client communication and collaboration across multidisciplinary teams to support regulatory inquiries and policy implementation.
Highest-signal resume keywords
Nurse Practitioner LicenseCPT/HCPCS Coding KnowledgeMedicare Coverage Policy ExpertiseAdvanced Excel SkillsClaims Editing Experience
Tech Stack
Tools & technologiesAbout the role
Key responsibilities & impact- Review monthly NCD/LCD change reports and vendor extracts to validate system configuration exclusions
- Verify CPT/HCPCS exclusions against client enforcement approaches and MAC jurisdiction rules
- Document completed configuration updates and track discrepancies through resolution
- Perform monthly client-specific policy and delta reviews and flag required updates
- Support transparency deliverables, including relevant code-change reports with MAC and CMS NCD/LCD references
- Maintain State Medicaid grids and the state requirements library
- Review enacted legislation for impacts 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 the primary contact for client regulatory questions through JIRA LPM/ACS tickets
- Prepare tailored client responses while excluding internal-only information
- Support Government Programs enforcement presentations during sales and implementation
- Assess state mandate requests and recommend whether variances 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 a commercial mandates grid and evolving the consultative client-support approach
- Collaborate with Operations, Legal, Configuration, Clinical, Product, and Government Affairs teams
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
- Strong understanding of Medicaid program structure
- Ability to read regulatory and legislative text and translate it 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
- Preferred: 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 work in quality assurance or audit functions
- Attention to detail and a strong control mindset
- Comfort with ambiguity and building processes where none exists
- Ability to collaborate across Operations, Legal, Product, and Clinical SMEs
- Diplomacy with clients, especially where positions differ
Benefits
Comp & perks- Eligible for remote work
- 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
Claims EditingPayment IntegrityUtilization ReviewCPT CodingHCPCS CodingICD-10 CodingRegulatory AnalysisData ValidationDelta/Comparison AnalysisPolicy Documentation
Soft Skills
Excellent Written CommunicationExcellent Verbal CommunicationAttention to DetailDiplomacy with ClientsComfort with Ambiguity
Tools & Technologies
JIRASharePointSOP Documentation ToolsSQLData Validation Tools
Certifications & Qualifications
CPCCCSCPC-P
Industry Keywords
NCDLCDMAC JurisdictionsState MedicaidLaboratory ServicesMolecular DiagnosticsGenetic Testing PolicyHealth Plan OperationsRegulatory ComplianceQuality Assurance