Remote Product Owner — Claims Editing & Revenue Impact

Avalon Healthcare Solutions; Tampa (FL); À distance; USD 110 000 - 150 000; Plein temps

Résumé du poste

Avalon Healthcare Solutions seeks a Product Owner, Claims Editing to drive automated claim edits across our programs. You will translate policy requirements into clear rule statements, model financial impact, and coordinate with Configuration and APEA Development to validate decisions.

You will develop training materials, test scenarios, and support client adoption, while monitoring edits for accuracy and revenue impact. Remote work is eligible with quarterly travel to Tampa.

Qualifications

• 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.
• Demonstrated 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.

Responsabilités

• 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 the 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.

Connaissances

Healthcare claims editing

SQL

Excel

Generative AI / LLMs

Cross-functional communication

Policy translation to rules

Formation

Bachelor’s degree or 8+ years experience in lieu of degree

Outils

APEA Edits platform

BI tools

APEA Development

Description du poste

Avalon Healthcare Solutions seeks a Product Owner, Claims Editing to drive automated claim edits across our programs. You will translate policy requirements into clear rule statements, model financial impact, and coordinate with Configuration and APEA Development to validate decisions.

You will develop training materials, test scenarios, and support client adoption, while monitoring edits for accuracy and revenue impact. Remote work is eligible with quarterly travel to Tampa.