AI-Driven Clinical & Reimbursement Policy Analyst

Industriasa; Northern (KY); Hybrid; USD 120,000 - 180,000; Full time

Benefits offered by this job

Remote-first culture

Career growth

Job summary

Clover Health is seeking an AI-forward Business Analyst, Clinical & Reimbursement Policy to own the lifecycle of clinical and reimbursement policies and translate CMS guidelines into actionable logic.

You will lead AI-enabled monitoring initiatives, manage external vendors, and collaborate with Clinical, Claims, and Compliance teams to ensure accurate adjudication in a remote-first environment.

Qualifications

• 5+ years in healthcare claims, configuration, or reimbursement policy.
• Strong AI-forward mindset for applying LLMs to research and monitoring.
• Medicare policy expertise with NCDs and LCDs.
• Experience managing vendor relationships at a strategic level.
• Preferred certifications: CPC, CCS, COC, or CIC.

Responsibilities

• Own development and maintenance of clinical and reimbursement policies aligned with CMS regulations.
• Interpret and operationalize NCDs, LCDs, and general national coding guidelines.
• Oversee external vendor performance with data-driven reviews and collaboration.
• Lead AI initiatives to automate monitoring of reimbursement policies using LLMs (Claude, Gemini, ChatGPT).
• Ensure policy intent is synchronized with technical adjudication with Configuration and Data Science teams.
• Bridge Clinical, Claims, and Compliance teams to unify payment excellence.

Skills

Medicare Advantage experience

AI/LLM expertise

Vendor management

Policy interpretation

Data dashboards / analysis

Education

Coding certifications (CPC/CCS/COC/CIC)

Tools

Claude

Gemini

ChatGPT

Job description

Clover Health is seeking an AI-forward Business Analyst, Clinical & Reimbursement Policy to own the lifecycle of clinical and reimbursement policies and translate CMS guidelines into actionable logic.

You will lead AI-enabled monitoring initiatives, manage external vendors, and collaborate with Clinical, Claims, and Compliance teams to ensure accurate adjudication in a remote-first environment.