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Business Analyst, Clinical & Reimbursement Policy

2 months, 3 weeks ago
United States
Full-time
Senior
Business Analyst
Data Science and Analytics
LLM
Apply Now
Clover Health

Clover Health

Clover Health is a data-focused health insurance company that is revolutionizing the Medicare Advantage space by integrating innovative technology into its plans. With a focus on optimizing medical outcomes and reducing costs, Clover Health uses analyt...

Insurance
251-1K
Founded 2014
$925M raised
View All Jobs 23

Description

  • Own the development and maintenance of clinical and reimbursement policies in alignment with CMS regulations.
  • Interpret and operationalize Medicare guidance, including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and national coding guidelines.
  • Oversee external vendor performance for policy monitoring and accuracy through data-driven reviews and workflow design.
  • Lead AI initiatives to automate reimbursement policy monitoring and conduct ongoing research using advanced LLM tools.
  • Partner with Configuration and Data Science teams to align policy intent with technical claims adjudication.
  • Act as the strategic bridge between Clinical, Claims, and Compliance teams to ensure consistent policy execution.
  • Establish recurring policy review frameworks and project plans to maintain policy library quality and compliance.
  • Use dashboards, trend analysis, and early-detection monitoring to improve policy oversight and adjudication accuracy.

Requirements

  • 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with a strong focus on Medicare Advantage.
  • Deep knowledge of Medicare regulations and experience interpreting and operationalizing complex clinical policies, NCDs, and LCDs.
  • Experience managing vendor relationships at a strategic level and holding external partners to performance standards.
  • Strong familiarity with AI tools and LLMs such as Claude, Gemini, and ChatGPT for research and monitoring.
  • Data-focused approach with the ability to build strategy from dashboards and trend analysis.
  • Experience with enterprise claims engines and how they support adjudication accuracy.
  • Preferred coding certification such as CPC, CCS, COC, or CIC.
  • Experience working in a Medicare Advantage environment.
  • Ability to stay current on regulatory updates and industry trends.
  • Experience collaborating across clinical, claims, compliance, configuration, and data science teams.

Benefits

  • Competitive base salary of $107,000 to $130,000 USD.
  • Equity opportunities, including an Employee Stock Purchase Plan (ESPP).
  • Performance-based bonus program and 401(k) matching.
  • Comprehensive medical, dental, and vision coverage.
  • Remote-first culture with flexible collaboration across locations.
  • Generous flexible time-off policy, plus No-Meeting Fridays and monthly company holidays.
  • Mental health resources and support.
  • Learning programs, mentorship, professional development funding, and regular feedback and reviews.
  • Reimbursement for office setup expenses.
  • Monthly cell phone and internet stipend.
  • Paid parental leave for all new parents.

Interested in this position?

Apply directly on the company website

Apply Now

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