Business Claims Associate

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 Business Claims Associate:

The Business Claims Associate will be a part of the Claims Operations Department and will report to the Claims Operations Supervisor. Responsibilities of the Claims Associate includes the submittal of weekly Provider Reconsideration faxes to multiple health plans and providing follow ups when appropriate. The Claims Associate will also upload faxed confirmations and health plan determination letters to in process tickets and will be expected to monitor Reconsideration queue to identify discrepancies. This role will also include performance of outbound calls and email communications to clients for status updates on tickets submissions to facilitate issue resolution. Additionally, the Claims Associate will evaluate provider issues presented on Provider Support tickets and work with the Senior team and management to determine trends and assist in driving resolution. Additionally, this role will include support of Network Operations. Furthermore, this position will also provide support for Network Operations, which includes the review and research of claims, verification of provider documentation, and the creation of ad-hoc reports

This position is eligible for hybrid-remote work and will be required to report to the corporate office in Tampa, Florida for 1-2 days per week.

Business Claims Associate - Essential Functions and Responsibilities:

• Submit Provider Reconsideration tickets to multiple Health plans
• Evaluate disputed claims in Reconsideration process and share findings with Senior staff to determine scope
• Maintain and update Provider demographic records for network participation.
• Uploading Health plan determination letters to appropriate Reconsideration tickets
• Track Provider issues and monitor trends to support their resolution.
• Update and responds to provider ticket requests within established turnaround times.
• Provides excellent customer service to providers.
• Collaborates with other departments to support provider needs.
• Performs outbound calls to Health Plans to investigate aging reconsideration submissions and claims payment details.
• Maintenance of various logs
• Excellent written and verbal communication skills.
• Research and resolve provider inquiries.
• Performs other duties as assigned.
• Storing and maintenance of multiple electronic documents.
• Ability to multi-task

Business Claims Associate - Minimum Qualifications:

• Good customer service and communication skills
• Attentive to details and organized
• Intermediate knowledge of Microsoft Office Suite products
• Excellent interpersonal skills
• Willingness to learn new skills
• Experience with using eFax and performing outbound phone calls to clients

Business Claims Associate - Minimum Qualifications:

• Associate degree preferred but not required
• Experience working in the health care industry is preferred but not required
• Experience with Provider credentialing is preferred but not required