Description

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. Learn more at www.avalonhcs.com.

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.

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.

For more information about Avalon, please visit www.avalonhcs.com.

About the Vice President, Operational Medical Director:

The Medical Director is a senior clinical leader within Avalon's Clinical Operations organization and serves as a key representative of the company on all clinical policy matters. This role is responsible for interpreting, applying, and advising on Avalon's evidence-based clinical policies for clients, with particular focus on policy customization, reconciliation, and implementation support. The Medical Director acts as a trusted clinical advisor to internal teams and external partners, ensuring policy integrity, clinical appropriateness, and alignment with client and market needs.

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

Vice President, Operational Medical Director  Essential Functions and Responsibilities:

• Serve as Avalon's senior clinical authority for policy interpretation, customization, and application, representing the organization on all clinical policy matters.
• Lead policy presentations and reconciliations for new client implementations and existing client policy expansions, guiding clients through policy selection and adoption.
• Act as a primary clinical liaison to health plan Medical Directors, Payment Integrity, and other senior clinical decision-makers, building trust and long-term partnerships.
• Support Account Management teams in client strategy, complex clinical discussions, and escalations, jointly defining client mission, strategy, and value delivery.
• Collaborate closely with the Scientific Affairs department, Coding and Translation teams, and Clinical Validation analysts to evaluate, validate, and refine policy logic and rule-based editing. 
• Provide expert clinical input on claims adjudication, policy application, and rule-based editing, ensuring accuracy, consistency, and clinical integrity.
• Identify and support value creation and growth opportunities by aligning clinical policy capabilities with client needs and expansion opportunities.
• Complete client-driven clinical inquiries and research requests in a timely manner, in partnership with the Chief Medical Officer and Clinical Policy teams.
• Present clinical policy updates, changes, and emerging considerations to Avalon's independent Clinical Advisory Board (CAB) and participate in quarterly CAB webinars.
• Partner with the Network team and external providers to support policy discussions, laboratory capability reviews, and evaluation of emerging diagnostic technologies, reinforcing Avalon's clinical credibility.

Vice President, Operational Medical Director  Minimum Qualifications:

• Degree in Medicine (MD/DO) - active or inactive license
• Minimum of 5 years of experience in a clinical setting
• Minimum of 3 years of experience in a payor or payment integrity vendor or similar organization
• Experience in health plan, Medicare or State Medicaid plans with focus on reimbursement and/or coding required
• Experience in supporting medical policy creation, enforcement and/or edits
• Experience in the private sector/health plan operations as a Medical Director, with knowledge/understanding of reimbursement policies and medical coding
• Demonstrated executive presence and comfortable working with clients directly
• Strong analytical and problem-solving skills
• Strong organizational skills and adaptive capacity for rapidly changing priorities and workloads
• Professional demeanor with ability to properly handle confidential information
• Ability to work well independently and in a team environment

Vice President, Operational Medical Director  Preferred Qualifications:

• Consulting experience within a healthcare coding and reimbursement company is a definite plus
• Data analysis proficiency preferred using Excel, SQL,and/or Tableau
• Prior experience in smaller, growth-stage company helpful

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