AI-Driven Medicare Policy Analyst (Remote)

Clover Health; United States; Remote; USD 120,000 - 180,000; Full time

Benefits offered by this job

Equity opportunities

401k matching

Performance-based bonus

Remote-first culture

Paid parental leave

Job summary

Clover Health is seeking a remote Business Analyst for Clinical & Reimbursement Policy. You will own policy development, maintenance, and CMS-aligned operations, translating Medicare guidelines into automated logic and overseeing vendor performance.

This role emphasizes AI-driven monitoring and cross-functional collaboration across Clinical, Claims, and Compliance teams. The ideal candidate has 5+ years in healthcare claims/reimbursement, Medicare expertise, and a passion for AI-enabled, precise

Qualifications

• 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with emphasis on Medicare Advantage.
• Proven ability to interpret Medicare guidelines (NCDs and LCDs) and operationalize them.
• Experience managing external vendor relationships and performance reviews.

Responsibilities

• Own the lifecycle of clinical and reimbursement policies aligned with CMS regulations.
• Translate Medicare guidelines into actionable logic for automated adjudication.
• Lead AI initiatives to automate monitoring of reimbursement policies using LLMs.
• Partner with Data Science and Configuration teams to synchronize policy intent with adjudication.
• Bridge Clinical, Claims, and Compliance teams to ensure payment excellence.

Skills

Healthcare claims experience

Regulatory interpretation

Medicare Advantage knowledge

AI-forward mindset

Vendor management

Education

Coding certifications (CPC, CCS, COC, or CIC)

Tools

Claude

Gemini

ChatGPT

Job description

Clover Health is seeking a remote Business Analyst for Clinical & Reimbursement Policy. You will own policy development, maintenance, and CMS-aligned operations, translating Medicare guidelines into automated logic and overseeing vendor performance.

This role emphasizes AI-driven monitoring and cross-functional collaboration across Clinical, Claims, and Compliance teams. The ideal candidate has 5+ years in healthcare claims/reimbursement, Medicare expertise, and a passion for AI-enabled, precise