Claims Editing Analyst, Genetics

About Avalon Healthcare Solutions:

Avalon Healthcare Solutions is the nation's leader in diagnostic intelligence, uniquely focused on transforming the role of diagnostic testing across the healthcare ecosystem. Our proprietary Diagnostic Insights Platform delivers evidence-based policies, curated lab networks, and real-time analytics that simplify complex diagnostics, accelerate innovation adoption, and optimize diagnostic investments.

Supporting over 30 health plans and 100 million members nationwide, Avalon partners with payers and providers to ensure diagnostic testing is performed appropriately, efficiently, and at the right time. Our flexible solutions span routine and genetic testing management, automated adherence, and end-to-end diagnostics support-driving measurable value, reduced waste, and improved clinical outcomes.

With unmatched scientific rigor, deep clinical expertise, and a performance-based model, Avalon is redefining how diagnostics power personalized care and healthcare value. 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.

Avalon Healthcare Solutions is an Equal Opportunity Employer - Vet/Disability.

This position description is subject to change at any time. As determined by the company based upon business needs, an employee in this position may be required to perform duties and take responsibility for work other than as described in this document.

About the Claims Editing Analyst, GTM Position:

The Claims Editing Content Analyst, Genetics Testing Management will identify, design, and support implementation of new automated claim edits that generate incremental value and revenue across Avalon's claim-editing programs. Initially focused on Genetic Test Management (GTM), the role will review existing and emerging policies with Scientific Affairs and Coding & Translation, identify opportunities for additional enforcement, translate those opportunities into configuration-ready rule statements, and model financial impact using claims data and approved AI tools. The analyst will coordinate with Configuration and Development through validation and rollout and support Product and Account Management with training, claim examples, and client adoption.

This role is designed for an early-career professional who already understands healthcare claims and has worked in claim editing or payment integrity for a health plan or an external organization. Success requires close reading of clinical and reimbursement policies, disciplined analytical thinking, and the ability to convert written requirements into precise, testable rules.

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

Claims Editing Analyst, GTM - Essential Functions and Responsibilities:

• 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 clinical and reimbursement policy requirements into clear, testable rule statements and configuration requirements, including applicable codes, triggers, exclusions, and expected outcomes.
• Evaluate combinations of CPT, HCPCS, PLA, ICD-10-CM, modifiers, place of service, provider and laboratory identifiers, authorization status, and other available claim data needed to apply edits accurately.
• Identify opportunities to automate policy enforcement for nonspecific molecular pathology codes, Tier 2 codes, unlisted codes, panels, and other genetic services that may be difficult to identify from a single claim field.
• Evaluate claim-editor capabilities and limitations and recommend new 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 claim decisions.
• 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, Development, Account Management, and analytics teams.

Claims Editing Analyst, GTM - Minimum Qualifications:

• Minimum years of relevant work experience: 3+ years in claims editing, payment integrity, medical coding, medical policy, or a related field.
• Minimum education: Bachelor's degree in a related field or 8+ years of applicable experience in lieu of a degree.
• Required certification: None
• Three 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 with close attention to detail.

Claims Editing Analyst, GTM - Preferred Qualifications:

• Direct experience developing, testing, or implementing automated claim edits or payment-integrity rules.
• Familiarity with genetic and genomic testing, molecular pathology coding, laboratory billing, or the diagnostic testing environment.
• Experience working for a health plan, claims-editing vendor, payment-integrity organization, or healthcare technology company.
• Experience developing or maintaining automated prepayment or post payment claim edits in a commercial editing platform or proprietary rules engine.