Clinical Quality Improvement Specialist

About the Company:

Avalon Healthcare Solutions, headquartered in Tampa, Florida, 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 across the country, the company covers more than 36 million lives and delivers 7-12% outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Platform 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 cost.

Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.

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. 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 proud to be an equal opportunity employer including disability/veteran. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.

Avalon Healthcare Solutions provides and maintains a drug-free workplace for its employees.

For more about Avalon, please visit our web site at http://www.avalonhcs.com.

About the Clinical Quality Improvement Specialist Position (RTM):

The Clinical 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 to the corporate office in Tampa, Florida may be required.

Clinical Quality Improvement Specialist - Essential Functions and Responsibilities:

• Establish annual QI Work Plan document which defines quality improvement priorities from both an activity and metric standpoint; update to insert data and information as received; conduct annual evaluation.
• 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.
• Develop and monitor Policy Operations and Enforcement quality reports.
• Policy Operations and Enforcement Data analytics.
• Review QI and Utilization Management Program Description documents; identify and act on any need for revision identified.
• 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.
• Manage and monitor clinical quality studies that may be undertaken by Avalon, to include receipt and analysis of trended data, assessment of national benchmarks as available, development of improvement recommendations (to include ROI and best practice interventions as appropriate), presentation to senior leadership, implementation of plan, and evaluation for desired result.
• Perform quality auditing based on data analytics reporting with a keen eye for inconsistent results.
• PRISM implementation/integration.
• Other duties as assigned by Manager.

Clinical Quality Improvement Specialist - Qualifications:

• Bachelors Degree or equivalent work experience
• 3-5 years of Health Care Quality Improvement experience in a managed care or health care services vendor relationship setting
• Certified Billing and Coder
• CPC (Certified Professional Coder) and/or CCS (Certified Coder Specialist), Certified Medical Auditor
• Working knowledge of Medical Policies and clinical coding.
• Strong knowledge of Health Plan claims, medical billing, and coding
• Expert proficiency in written and oral communication skills required.
• Expert proficiency in computer skills including Microsoft Office Suite products - Excel proficiency is 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.

Clinical Quality Improvement Specialist - Preferred Qualifications:

• 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
• Experience working with proprietary developed programs.
• Knowledge of and experience with laboratory medical coding rules and regulations, compliance, reimbursement, bundling issues.
• Experience with data analysis tools (SQL, PowerBI, JIRA)
• Experience with Agile/Scrum principles
• Certification in Healthcare Quality
• Biology, chemistry, medicine, nursing, medical technology, or related field of education

PM18

PI238529688