Business Analyst, Clinical & Reimbursement Policy
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Job Description
Business Analyst translating Medicare regulations into automated clinical and reimbursement policies for Clover Health, a data-driven health insurer. Leading AI monitoring, vendor oversight, and claims adjudication accuracy.
Responsibilities:
- Own development and maintenance of clinical and reimbursement policies aligned with CMS regulations
- Interpret and operationalize Medicare guidelines, including NCDs, LCDs, and national coding guidelines
- Oversee external vendor performance for policy monitoring and accuracy
- Conduct data-driven vendor performance reviews and design collaborative workflows
- Lead AI initiatives to automate reimbursement policy monitoring
- Use Claude, Gemini, and ChatGPT for deep research on industry trends
- Partner with Configuration and Data Science teams to synchronize policy intent with technical adjudication
- Bridge Clinical, Claims, and Compliance teams around payment excellence
- Establish a recurring review framework and project plan for the policy library
- Keep policies current with regulatory requirements
- Implement AI-forward oversight and early-detection monitoring frameworks
Requirements:
- 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with heavy emphasis on Medicare Advantage
- AI-forward mindset and passion for applying emerging technologies and LLMs to research and monitoring
- Medicare expertise interpreting and operationalizing complex clinical policies, NCDs, and LCDs
- Proven experience managing strategic vendor relationships and enforcing rigorous performance standards
- Data-focused approach using dashboards and trend analysis
- Familiarity with enterprise claims engines and their role in adjudication accuracy
- Coding certifications such as CPC, CCS, COC, or CIC are preferred qualifications
Benefits:
- Competitive base salary
- Equity opportunities
- Performance-based bonus program
- 401k matching
- Regular compensation reviews
- Comprehensive medical, dental, and vision coverage
- No-Meeting Fridays
- Monthly company holidays
- Mental health resources
- Generous flexible time-off policy
- Remote-first culture
- Learning programs
- Mentorship
- Professional development funding
- Regular performance feedback and reviews
- Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone & internet stipend
- Collaboration with global teams
- Paid parental leave for all new parents
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