Remote Quality Improvement Specialist-Healthcare Analytics

Avalon Healthcare Solutions; Tampa (FL); Remote; USD 65,000 - 95,000; Full time

Job summary

Avalon Healthcare Solutions is seeking a Quality Improvement Specialist to lead QI activities aligned with organizational priorities. You will collaborate across departments to interpret policies, review claims data, and drive measurable quality improvements.

This role supports remote work with quarterly travel to Tampa, FL. The position emphasizes auditing, metric monitoring, and cross-functional teamwork to enhance clinical outcomes and efficiency in laboratory billing and reimbursement

Qualifications

• 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 and/or CCS, CPMA.
• Working knowledge of Medical Policies and medical coding.
• Strong knowledge of Health Plan claims, medical billing, and medical coding.
• Excellent written and oral communication skills.
• Advanced computer skills including Microsoft Office (Excel required).
• Strong understanding of health insurance claims and terminology.
• Interpersonal, independent and team work skills.
• Strong organizational skills.

Responsibilities

• Manage and monitor quality auditing including receipt and analysis of claims data, development of improvement recommendations, implementation of plan, and evaluation for desired result.
• Perform quality auditing based on data analytics reporting on claims data with a keen eye for inconsistent results.
• Complete work on a monthly and quarterly cadence to deliver quality auditing findings and recommendations.
• Collaborates with Medical Policy, Configuration, Policy and Enforcement, Coding and Translation departments to reflect medical and claims policies.
• Monitor required QI Work Plan metric trends, identify variation, convene teams to conduct root cause analysis and drive actions.
• Establish annual QI Work Plan with priorities and metrics; update with data and information received.
• Set agenda and prepare Quality Improvement Committee materials to drive outcomes.
• Perform various department functions including client health plan delegation oversight and internal auditing functions; review policies.
• Other duties as assigned by Manager.

Skills

Quality improvement

Medical coding knowledge

Healthcare claims

Communication skills

Data analysis

Education

Bachelor’s degree or equivalent

Tools

SQL

Power BI

JIRA

Microsoft Excel

Job description

Avalon Healthcare Solutions is seeking a Quality Improvement Specialist to lead QI activities aligned with organizational priorities. You will collaborate across departments to interpret policies, review claims data, and drive measurable quality improvements.

This role supports remote work with quarterly travel to Tampa, FL. The position emphasizes auditing, metric monitoring, and cross-functional teamwork to enhance clinical outcomes and efficiency in laboratory billing and reimbursement