Quality Improvement Specialist

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 Quality Improvement Specialist:

The Quality Improvement Specialist facilitates the establishment of QI activities and methods of measurement that are prioritized to organizational priorities. This position collaborates with various functional areas to understand and alleviate obstacles as needed and monitors for successful performance via the Quality Improvement Committee.

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

Quality Improvement Specialist - Essential Functions and Responsibilities:

• Manage and monitor quality auditing that may be undertaken by Avalon, to include receipt and analysis of claims data, development of improvement recommendations, implementation of plan, and evaluation for desired result.
• Perform quality auding 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 accurately reflect medical and claims payment policies.
• Monitor required QI Work Plan metric trends, identify variation, convene functional area or cross-functional teams as needed to conduct root cause analysis and institute meaningful action to achieve defined performance goals.
• Establish annual QI Work Plan which defines quality improvement priorities from both an activity and metric standpoint; update to insert data and information as received; conduct annual evaluation.
• Set agenda/create Quality Improvement Committee meeting materials to drive desired meeting outcomes and ensure proper recording of committee activities.
• Perform various department functions and processes, such as those associated with client health plan delegation oversight, internal auditing functions, and annual QI/UM operational policy review and revision.
• Other duties as assigned by Manager.

Quality Improvement Specialist - Minimum 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 (Certified Professional Coder) and/or CCS (Certified Coder Specialist), CPMA (Certified Professional Medical Auditor)
• Working knowledge of Medical Policies and medical coding.
• Strong knowledge of Health Plan claims, medical billing, and medical coding
• Expert proficiency in written and oral communication skills required.
• Expert proficiency in computer skills including Microsoft Office Suite products (Excel a must).
• Strong understanding of health insurance claims and terminology.
• Strong communication, delivery, and presentation skills.
• Strong understanding of laboratory billing and reimbursement practices.
• High attention to detail and documentation.
• Clinical experience with a background of ICD-10, CPT, and HCPCS coding principles.
• Exceptional interpersonal skills with demonstrated ability to work independently as well as with a team.
• Strong organizational skills.

Quality Improvement Specialist - Qualifications Preferred:

• Experience with Centers for Medicare & Medicaid Services (CMS) and industry standard billing, compliance, and reimbursement methodologies.
• Lab/Genetic test experience/familiarity.
• Familiarity with commercial payor medical policies
• Knowledge of and experience with laboratory medical coding rules and regulations, compliance, reimbursement, bundling issues.
• Experience with data analysis tools (SQL, PowerBI, JIRA)
• Certification in Healthcare Quality
• Biology, chemistry, medicine, nursing, medical

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