Business Analyst, Clinical & Reimbursement Policy

Industriasa; United States; 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

At Clover Health, we’re focused on improving the health of our members by leveraging technology and data-driven insights to provide personalized, high-quality care. As a Medicare Advantage plan, we aim to empower our members by helping them navigate the complexities of healthcare and live healthier lives. We are passionate about making healthcare easier, more affordable, and more accessible for everyone.

We are looking for an AI-forward Business Analyst, Clinical & Reimbursement Policy to serve as the strategic bridge between regulatory requirements and automated execution. In this high-impact role, you will be responsible for the end-to-end lifecycle of Clover’s clinical and reimbursement policies, ensuring they are accurately interpreted, regularly updated, and seamlessly integrated into our claims environment. You will act as a primary Subject Matter Expert (SME), translating complex Medicare guidelines—including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)—into actionable logic. You will also play a critical role in vendor management, partnering with external vendors to enhance policy oversight. Your mission is to accelerate Clover's transition toward a high-precision payment ecosystem where monitoring and research are highly automated, ensuring clinical and reimbursement policies are seamlessly and accurately operationalized.

As a Business Analyst, Clinical & Reimbursement Policy, you will:

• Policy Lifecycle & Compliance: Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations.
• Medicare Regulatory SME: Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and general national coding guidelines.
• Strategic Vendor Management: Serve as the primary oversight for external vendor performance regarding policy monitoring and accuracy. Hold partners to world-class standards through data-driven performance reviews and collaborative workflow design.
• AI-Driven Evolution: Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies. Utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to conduct regular deep research on ongoing industry trends.
• System Integration: Partner with the Configuration and Data Science teams to ensure that clinical and reimbursement policy intent is perfectly synchronized with technical adjudication.
• Cross-Functional Influence: Act as the strategic bridge between Clinical, Claims, and Compliance teams to ensure a unified vision of payment excellence.

Success in this role looks like:

• By the end of your initial 90-day period: You will have established a recurring review framework and a comprehensive project plan for Clover's clinical and reimbursement policy library to ensure baseline quality and strict adherence to clinical guidelines.
• By 6 months: You will have ensured that all existing clinical and reimbursement policies are current and up to date, reflecting the latest regulatory requirements. You will also have implemented an AI-forward oversight framework that utilizes advanced research tools and early-detection monitoring to enhance accuracy within our adjudication systems. You will be actively leveraging AI tools like Claude, Gemini, and ChatGPT to perform deep-dive research on industry trends and regulatory updates.
• Continued success: You will lead the evolution of Clover’s policy management into a proactive strategic powerhouse. By championing automated monitoring and data-driven research, you will ensure Clover’s payment ecosystem achieves market-leading precision and technological sophistication.

Qualifications:

• You have 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with a heavy emphasis on Medicare Advantage.
• You are extremely AI-forward and are passionate about how emerging technologies and LLMs (Claude, Gemini, ChatGPT, etc.) can be applied to drive operational precision in research and monitoring.
• You are a Medicare expert with a proven track record of interpreting and operationalizing complex clinical policies, NCDs, and LCDs.
• You have experience managing vendor relationships at a strategic level, ensuring external partners meet rigorous performance standards.
• Preferred qualifications include coding certifications such as CPC, CCS, COC, or CIC.
• You are a data-focused professional who builds strategy based on dashboards and trend analysis.
• You are familiar with enterprise claims engines and understand how these systems interact to drive adjudication accuracy.

Benefits Overview:

Financial Well-Being:

Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.

Physical Well-Being:

We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.

Mental Well-Being:

We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.

Professional Development:

Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development fu…