Product Owner, Claims Editing

Avalon Healthcare Solutions

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

Posted 10/8/2026full-timeRemote • Florida • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare 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 drive operational improvements and financial performance.

Highest-signal resume keywords

Healthcare Claims EditingClaims AnalyticsMedical Coding SystemsAI and Large Language ModelsSQL and Data Visualization

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationPayment IntegrityAutomated Claim EditingBusiness Rules TranslationData Analysis

Soft Skills

Analytical SkillsDocumentation SkillsPresentation SkillsCross-Functional Communication

Tools & Technologies

ExcelSQLBusiness-Intelligence ToolsAPEA Claims-Editing PlatformAgile Development

Industry Keywords

Healthcare TechnologyMedical PolicyReimbursementGenetic TestingRadiology Claims

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 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

What you’ll need

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

Comp & perks

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