Clinical Policy & Gov't Programs Specialist

About the job

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 Clinical Policy & Government Programs Specialist Position: Avalon Healthcare Solutions is seeking a detail-oriented and clinically grounded Clinical Policy & Government Programs Specialist to support the delivery of key regulatory and compliance functions, including NCD/LCD Enforcement Validation, State Medicaid Alignment, and Client Regulatory Advisory Support. This role is critical to ensure our claim-edit configuration remains accurate, timely, and aligned with Medicare and state Medicaid requirements. It is also critical for providing health plan clients with clear, trusted guidance on how our policies and enforcement approaches operate, while respecting the boundary between subject matter expertise and legal advice. The ideal candidate is a licensed Nurse Practitioner with a coding background, strong analytical skills, and a proven track record of interpreting regulatory and coverage policy and translating it into operational impact. Additionally, this individual is expected to demonstrate sound judgment, a strong control mindset, and the ability to build trusted partnerships across Operations, Legal, Configuration, and Clinical teams, helping create an environment of high-integrity performance and continuous improvement. This position is eligible for remote work, but travel to the corporate office in Tampa, Florida or other locations is required. Clinical Policy & Government Programs Specialist – Essential Functions and Responsibilities: NCD/LCD Enforcement & Configuration Validation • Review the monthly NCD/LCD change report and the vendor-supplied extract, and confirm exclusions are accurately reflected in system configuration. • Verify CPT/HCPCS exclusions follow each client's enforcement approach (Cost Savings or CPT Code Match) and MAC jurisdiction rules. • Maintain documented confirmation that configuration updates were completed, stored in the agreed repository. • Escalate discrepancies to Configuration and Operations and track them to resolution. 2. Client-Specific Policy and Delta Reviews • Perform monthly delta reviews for clients that embed NCD/LCD language directly in their policies, and flag required policy updates. • Support monthly transparency deliverables, such as change reports listing codes added or removed with the applicable MAC and CMS NCD/LCD reference. • Compare change reports against each client's applicable code list so clients see only relevant changes. 3. State Medicaid & Regulatory Alignment • Maintain and update State Medicaid grids and the state requirements library. • Review enacted legislation monthly for impact on laboratory policies and operations, and update grids when needed. • Identify potential conflicts between base policies and state Medicaid requirements and support policy reconciliation discussions. • Build out research for new states as they come into scope. 4. Client Support & Advisory • Serve as the primary point person for client regulatory questions (JIRA LPM/ACS tickets), engaging Clinical MD SMEs and Legal/Government Affairs as needed. • Prepare client-friendly, tailored responses that exclude internal-only information. • Support the Government Programs enforcement presentation during sales and implementation and answer GovPro questions during policy reconciliation. • Assess client state mandate requests by reviewing the exact mandate language against the translation document and recommend whether a variance should be considered. 5. Process Improvement & Special Projects • Document SOPs, define ownership, and strengthen controls and monitoring. • Evaluate AI-assisted approaches for research and regulatory review. • Support projects such as building commercial mandates grid or evolving consultative approach to client support. Clinical Policy & Government Programs Specialist – Minimum Qualifications: • Minimum years of relevant work experience: 7 years • Minimum education: Bachelor of Science in Nursing / Master of Science in Nursing • Required certification: N/A • Previous or Active, unrestricted U.S. license as a Nurse Practitioner (NP). • Professional coding credential (e.g., CPC, CCS, CPC-P) or equivalent experience. • 3+ years of experience in claims editing, payment integrity, coding/auditing, utilization review, or health plan operations. • Working knowledge of CPT, HCPCS, and ICD-10 coding. • Strong understanding of Medicare coverage policy (NCDs, LCDs, MAC jurisdictions) and Medicaid program structure. • Strong research skills, with the ability to read regulatory and legislative text and translate it into operational impact. • Advanced Excel skills (lookups, large data sets, delta/comparison analysis). • Excellent written and verbal communication, including writing clearly for non-clinical client audiences. • Sound judgment on where advisory support ends and legal advice begins. Clinical Policy & Government Programs Specialist – Preferred Qualifications: • Experience with laboratory services, molecular diagnostics, or genetic testing policy. • Experience with a claim-editing or payment integrity platform. • Direct health plan client-facing experience. • Familiarity with JIRA, SharePoint, and SOP/policy documentation tools. • Experience with SQL or data validation tools. • Prior work in quality assurance or audit functions. • Attention to detail and a strong control mindset. • Comfort with ambiguity and building process where none exists. • Collaboration across Operations, Legal, Product, and Clinical SMEs. • Diplomacy with clients, especially where positions differ.