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.

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

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

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