Remote Clinical Policy & Government Programs Specialist

Avalon Healthcare Solutions; Tampa (FL); Remote; USD 95,000 - 150,000; Full time

Job summary

Avalon Healthcare Solutions seeks a detail-oriented Clinical Policy & Government Programs Specialist to support regulatory functions, including NCD/LCD enforcement validation and state Medicaid alignment. The role emphasizes translating policy into operational impact for clients across operations, legal, and clinical teams.

The ideal candidate is a licensed NP with a coding background and strong analytical skills, capable of building trusted partnerships and guiding regulatory advisory services.

Qualifications

• Licensed Nurse Practitioner with an active U.S. license.
• Professional coding credential (e.g., CPC, CCS, CPC-P) or equivalent experience.
• 7+ years of relevant healthcare policy, regulatory, or claims-edit experience.
• Strong knowledge of CPT, HCPCS, and ICD-10; Medicare/Medicaid policy understanding.
• Excellent written and verbal communication for non-clinical client audiences.
• Advanced Excel skills and data analysis capabilities.

Responsibilities

• Validate NCD/LCD enforcement and configure system updates.
• Perform monthly delta reviews and prepare transparent client reports.
• Maintain State Medicaid grids and review enacted legislation for impact.
• Serve as primary client regulatory advisor and coordinate with MD SMEs and Legal.
• Document SOPs, explore AI-assisted approaches, and support special projects.

Skills

NP license

Coding credentials

Regulatory knowledge

Regulatory interpretation

Analytical skills

Education

BSN/MSN

Tools

JIRA

SharePoint

Policy documentation tools

SQL

Job description

Avalon Healthcare Solutions seeks a detail-oriented Clinical Policy & Government Programs Specialist to support regulatory functions, including NCD/LCD enforcement validation and state Medicaid alignment. The role emphasizes translating policy into operational impact for clients across operations, legal, and clinical teams.

The ideal candidate is a licensed NP with a coding background and strong analytical skills, capable of building trusted partnerships and guiding regulatory advisory services.