Manager, Policy Coding and Translation (Healthcare Plan)

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 .

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 .

About the Manager, Policy Coding and Translation:

Reporting to the Leader of the Policy Operations and Enforcement department, the Manager, Policy Coding and Translation oversees the development, maintenance, and implementation of coding processes for laboratory and clinical policies. This position ensures that updates to PLA, AMA HCPCS, and ICD-10 codes are incorporated into managed care policies and that the coding and translation team operates efficiently and with high quality.

In addition to managing the team, this positing collaborates with cross-functional departments to ensure coding aligns with claims adjudication and policy enforcement. This role also involves continuous process evaluation and improvement, infrastructure management, and providing subject matter expertise during configuration and policy design sessions. The Manager, Policy Coding and Translation is responsible for meeting client SLAs by ensuring timely and accurate completion of work while maintaining quality standards. This is a working manager role, blending both individual contributor tasks with leadership responsibilities.

This position is eligible for remote work, but quarterly travel to the corporate office in Tampa, Florida is required.

Manager, Policy Coding and Translation ¢â‚¬" Essential Functions and Responsibilities:

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  Policy Development, Maintenance, and Updates:
  • Develops and maintains controlled documentation for coding and translation of laboratory and clinical policies.
  • Integrates annual updates for PLA, AMA HCPCS, and ICD-10 codes into policies.
  • Contributes to the development and enforcement of medical policy rules, including rationale, evidence, and documentation for interpretation and implementation.
  • Provides expertise in translating medical and payment policies into actionable claims adjudication logic, ensuring all updates are integrated seamlessly.
  • Collaborates with Medical Policy, Configuration, Claims Operations, and Client Success departments to ensure that coding and configuration accurately reflect medical and claims payment policies.
• 
  Team Leadership and Process Management:
  • Manages the coding and translation team, providing leadership, training, and support to ensure accuracy and quality.
  • Builds and maintains infrastructure to ensure work is assigned, researched, and completed on schedule.
  • Develops training materials to ensure work quality, and continually analyzes processes to identify and document opportunities for improvement.
  • Participates in design/build sessions, offering input on configuration solutions, assessing risks and impacts on processes, and supporting client inquiries.
  • Continuously evaluates existing coding and policy translation processes to improve efficiency, effectiveness, and adherence to quality standards.
  • Other duties as assigned.

Manager, Policy Coding and Translation ¢â‚¬" Minimum Qualifications:

• Bachelor's degree in Business or related area.
• 2 years' experience in health care management required, ideally with a health maintenance organization or health insurance carrier.
• 5 or more years' experience in claims systems as related to translation and coding.
• Analytical and project management skills, including a thorough understanding of how to interpret customer business needs and translate these into application requirements.
• Able to make processing decisions in exceptional claim situations.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Experience working with multiple processes and serving customers.
• Knowledge of professional operations and interdependencies with applications supporting the patient care process.
• Proficient with Microsoft Office products including Word, PowerPoint, and Excel
• Demonstrated experience in translating and coding policy documents with a keen eye for detail and accuracy.
• Excellent written and verbal communication skills, with the ability to communicate complex ideas in a clear and accessible manner.
• Ability to adapt to changing priorities, tight deadlines, and handle multiple projects simultaneously.
• A proactive and adaptable attitude, capable of thriving in a fast-paced and dynamic work environment.

Manager, Policy Coding and Translation ¢â‚¬" Preferred Qualifications:

• Previous experience in an early-stage growth company helpful.
• CPC designation strongly preferred.

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