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Avalon Healthcare SolutionsCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Health Care Quality Improvement, including quality auditing, claims data analysis, and the establishment of quality improvement activities. Proficient in medical coding principles and health insurance claims, with strong communication and organizational skills to facilitate collaboration across functional teams.
Highest-signal resume keywords
Health Care Quality Improvement ExperienceCertified Professional Coder (CPC)Data Analysis Tools (SQL, PowerBI)Expert Proficiency in Microsoft Office SuiteKnowledge of Medical Policies and Coding
Tech Stack
Tools & technologiesAbout the role
Key responsibilities & impact- Facilitate the establishment of quality improvement activities and measurement methods aligned with organizational priorities
- Collaborate with functional areas to understand and alleviate obstacles
- Monitor successful performance through the Quality Improvement Committee
- Manage and monitor quality auditing, including claims data receipt and analysis, improvement recommendations, plan implementation, and evaluation of results
- Perform quality auditing based on claims-data analytics and identify inconsistent results
- Deliver quality auditing findings and recommendations on monthly and quarterly cadences
- Collaborate with Medical Policy, Configuration, Policy and Enforcement, Coding, and Translation departments to reflect medical and claims payment policies accurately
- Monitor QI Work Plan metric trends and identify variation
- Convene functional or cross-functional teams for root cause analysis and meaningful corrective action
- Establish and maintain the annual QI Work Plan, including priorities, activities, metrics, updates, and annual evaluation
- Set agendas and create Quality Improvement Committee materials to drive meeting outcomes and record committee activities
- Perform client health plan delegation oversight, internal auditing, and annual QI/UM operational policy review and revision
- Perform other duties as assigned by the Manager
Requirements
What you’ll need- 3-5 years of Health Care Quality Improvement experience in a managed care or health care services vendor relationship setting
- Bachelor's degree or equivalent experience
- Certified Billing and Coder: CPC (Certified Professional Coder) and/or CCS (Certified Coder Specialist), CPMA (Certified Professional Medical Auditor)
- Working knowledge of Medical Policies and medical coding
- Strong knowledge of Health Plan claims, medical billing, and medical coding
- Expert proficiency in written and oral communication skills
- Expert proficiency in computer skills including Microsoft Office Suite products (Excel a must)
- Strong understanding of health insurance claims and terminology
- Strong communication, delivery, and presentation skills
- Strong understanding of laboratory billing and reimbursement practices
- High attention to detail and documentation
- Clinical experience with ICD-10, CPT, and HCPCS coding principles
- Exceptional interpersonal skills with demonstrated ability to work independently as well as with a team
- Strong organizational skills
- Experience with Centers for Medicare & Medicaid Services (CMS) and industry standard billing, compliance, and reimbursement methodologies
- Lab/Genetic test experience/familiarity
- Familiarity with commercial payor medical policies
- Knowledge of and experience with laboratory medical coding rules and regulations, compliance, reimbursement, bundling issues
- Experience with data analysis tools (SQL, PowerBI, JIRA)
- Certification in Healthcare Quality
- Biology, chemistry, medicine, or nursing background
Benefits
Comp & perks- Eligible for remote work
- Quarterly travel to Avalon's corporate office in Tampa, Florida
- 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
Quality AuditingClaims Data AnalysisICD-10 CodingCPT CodingHCPCS CodingHealth Plan ClaimsMedical BillingLaboratory Billing PracticesQuality Improvement MetricsRoot Cause Analysis
Soft Skills
Expert Communication SkillsInterpersonal SkillsOrganizational SkillsAttention to DetailTeam Collaboration
Tools & Technologies
Microsoft ExcelPowerBISQLJIRA
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Coder Specialist (CCS)Certified Professional Medical Auditor (CPMA)Certification in Healthcare Quality
Industry Keywords
Managed CareHealth Care ServicesCenters for Medicare & Medicaid Services (CMS)Billing ComplianceReimbursement MethodologiesMedical PoliciesLaboratory Medical CodingCommercial Payor Policies