Clinical Policy Manager - Military veterans preferred

About Avalon Healthcare Solutions:

Avalon Healthcare Solutions is the world's first and only Lab Insights company, bringing together our proven Lab Benefit Management solutions, lab science expertise, digitized lab values, and proprietary analytics to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Working with health plans nationwide, the company covers over 44+ million lives and delivers 10-20% proven outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Program that captures, digitizes, and analyzes lab results in real-time to provide actionable insights for earlier disease detection, ensuring appropriate treatment protocols and driving down overall costs. 

Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies. Avalon is a high growth company where every associate has an opportunity to make a difference. 

Avalon has years of expertise in managing lab benefits and now is leveraging digitized lab results to drive quality clinical outcomes and proven savings.  When you look at how we bring this to life, we offer Lab Insights solutions that work together to arm you with critical lab-driven insights to accelerate your value-driven care success.  This is the first-of-its-kind suite of solutions to help you achieve the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per-member cost of healthcare.

You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.

For more information about Avalon, please visit www.avalonhcs.com.

About the Clinical Policy Manager:

The Clinical Policy Manager (CPM) is part of the Policy Operations and Enforcement Team, reporting to the Senior Manager, Configuration. The Clinical Policy Manager is responsible for providing clinical oversight and decisioning around policy creation, client inquiry, and critical functions related to both Service and Implementation. The CPM will be responsible for managing inquiries from multiple sources, extensive research, and travel to clients in the process of implementation. The CPM is expected to lead policy reconciliation efforts with confidence, managing trackers and facilitating client decisions that lead to maintenance of value for both the client and Avalon. Occasionally, the CPM will be asked to support the CMO in client discussions. The CPM shall provide oversight, on request, of regression testing to ensure outcomes match clinical logic. This role requires galvanizing, and tenacity, to successfully meet responsibilities. 

This position is eligible for remote work, but quarterly travel will be required to Avalon's corporate office located in Tampa, Florida.

Clinical Policy Manager – Essential Functions and Responsibilities:

• Provide clinical guidance in Sales, Business Development, Service, and other roles as needed in the function of policy research 
• Provide clinical guidance in new and reviewing policies, directly giving counsel to Scientific Affairs in policy work, resulting in clinically confident policy structure 
• Lead client facing in-person policy reconciliation occurring during Implementation 
• Respond to ongoing client-facing questions, clinical in nature and requiring a response with the appropriate credentials, as funneled from service team 
• Participate in RCV and review the state library to understand requirements and policy and translation enforcement are aligned
• Review state and federal notifications for clinical impact to business  
• Possess a strong ability to interact with clients, develop a deep understanding of the process and can fully support implementation 
• Support Sales in early-stage discussions, walking through the process of implementation 
• Soft skills – business communication, presentation skills, unflappable, concise communication, detail oriented
• Develop process documents over time to support standardization of role and implementations 
• As required, serve as support to CMO in client facing implementation conversations 
• Research client questions, seeking clarification from partners
• Support broader immediate team, Sales, Business Development, Service, and CMO on policy research  
• Initial support with current Implementation Team 

Clinical Policy Manager – Minimum Qualifications:

• Bachelor’s degree, BSN preferred, or RN, PA, or NP 
• Certified Professional Coder (CPC), or willingness to get CPC certification within the 1st year after hire
• SAFe certification, or willingness to obtain SAFe certification
• Minimum of 10 years combined professional experience, including: 
  • 3-5yrs of clinical experience working on the hospital floor or for a physician’s office.
  • 3-5 years of healthcare research experience, rule writing experience etc. obtained via working for a Health Plan or Payment Integrity Vendor (or similar)
  • 1-3 years of billing and claims processing experience obtained via working for a Health Plan or Payment Integrity Vendor (or similar)
• Must have the ability to interact and discuss complex, clinical/scientific claim editing policies with clients and clinical staff as well as the ability to utilize Word, Power Point, Excel to create and present policies/data to client/clinical staff

Clinical Policy Manager – Qualifications Preferred:

• Licensed RN, PA, or NP
• 1-3 years of coding experience (professional/outpatient preferred)
• 1-3 years of claim adjudication platform experience, including configuration of rules, exceptions, exclusions etc. 
• Exposure to Claims adjudication lifecycle, CMS edits, NCD/LCD, NCI edits

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