Supervisor, Quality Improvement - Healthcare Claims & Payment

Supervisor, Quality Improvement

This role focuses on healthcare claims auditing, reimbursement methodologies, payment accuracy, coding quality, data analysis, and quality improvement initiatives. Successful candidates typically possess experience in healthcare claims operations, quality auditing, medical billing, reimbursement review, coding validation, and process improvement, along with working knowledge of ICD-10, CPT, and HCPCS coding principles. Prior supervisory or team leadership experience is required. Experience with SQL, Power BI, JIRA, or similar reporting and analytics tools is preferred. The Supervisor, Quality Improvement is responsible for overseeing Avalon's quality improvement auditing and monitoring activities while leading a team of Quality Improvement Specialists. This position serves as a working leader, directly participating in quality audits, data analysis, reporting, and process improvement initiatives while ensuring the team consistently delivers accurate, timely, and actionable quality insights. The Supervisor collaborates across Clinical Operations, Medical Policy, Configuration, Coding, Translation, Client Delivery, and other operational teams to support Avalon's Quality Improvement Program, identify opportunities for improvement, and drive performance against organizational goals, client requirements, and regulatory standards.

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

Supervisor, Quality Improvement Essential Functions and Responsibilities

• Supervise, coach, develop, and evaluate a team of Quality Improvement Specialists
• Establish team goals, performance expectations, and productivity standards
• Monitor workload distribution and ensure timely completion of quality audits, reporting, and improvement initiatives including ad hoc requests and shifting of priorities as new tasks arise.
• Provide ongoing training, mentoring, and professional development opportunities
• Support hiring, onboarding, performance management, and succession planning activities
• Foster a culture of accountability, continuous improvement, collaboration, and customer service
• Perform and oversee quality auditing activities, including review and analysis of claims data, identification of trends, development of recommendations, and monitoring of corrective actions
• Review audit findings and reports for accuracy, consistency, and completeness
• Monitor quality performance metrics and identify opportunities for process improvement
• Conduct root cause analyses and facilitate corrective action planning with operational stakeholders
• Support development, implementation, and evaluation of quality improvement initiatives
• Ensure quality activities are aligned with organizational priorities, client expectations, and regulatory requirements
• Complete and oversee monthly, quarterly, and annual quality reporting activities
• Assist in the development, maintenance, and evaluation of the annual Quality Improvement Work Plan
• Monitor QI Work Plan metrics and performance trends, escalating concerns and recommending solutions as appropriate
• Support delegation oversight activities, internal audits, and operational policy reviews
• Collaborate with cross-functional teams to ensure accurate implementation of medical and claims payment policies
• Analyze claims, operational, and quality performance data to identify trends, risks, and opportunities
• Develop and present quality performance reports, audit findings, and recommendations to leadership
• Ensure accuracy and integrity of quality data, reporting methodologies, and audit documentation
• Partner with operational leaders to measure effectiveness of improvement initiatives and validate outcomes

Supervisor, Quality Improvement Minimum Qualifications

• 5+ years of healthcare quality improvement, auditing, claims analysis, or related healthcare operations experience
• 23 years of supervisory, team lead, or people leadership experience
• Bachelor's degree in Healthcare Administration, Business, Nursing, Health Information Management, or a related field or equivalent combination of education and relevant experience
• Strong knowledge of healthcare claims processing, medical billing, reimbursement methodologies, and medical coding
• Working knowledge of ICD-10, CPT, and HCPCS coding principles
• Experience conducting quality audits and translating findings into process improvements
• Strong analytical and problem-solving skills with high attention to detail
• Advanced Microsoft Excel skills and proficiency with Microsoft Office applications
• Strong written, verbal, and presentation skills
• Ability to prioritize multiple projects and deadlines in a fast-paced environment
• Demonstrated leadership, coaching, and employee development capabilities
• Ability to build effective working relationships across departments

Supervisor, Quality Improvement Preferred Qualifications

• CPC (Certified Professional Coder), CCS (Certified Coding Specialist), and/or CPMA (Certified Professional Medical Auditor) certifications preferred
• Experience in a managed care, payer, or healthcare services organization
• Experience supporting Quality Improvement or NCQA-related programs
• Laboratory, genetic testing, or diagnostic management experience
• Experience with Power BI, SQL, JIRA, or similar reporting and analytics tools
• Certification in Healthcare Quality (CPHQ) preferred
• Clinical, coding, compliance, or health information management background