Remote AI-Driven Clinical & Reimbursement Policy Analyst

Clover Health; United States; Remote; USD 107,000 - 130,000; Full time

Benefits offered by this job

Remote-first culture

Competitive base salary

Equity opportunities

401k matching

Performance-based bonus

ESPP

Job summary

Clover Health is seeking an AI-forward Business Analyst, Clinical & Reimbursement Policy to translate Medicare guidelines into actionable policy logic for Clover’s claims environment. Remote-USA position requiring deep expertise in CMS regulations and policy lifecycle.

You will lead AI initiatives, work with external vendors, and collaborate across Clinical, Claims, and Compliance to ensure precise, automated policy operation and mentorship of the policy library to meet regulatory standards and

Qualifications

• 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with a heavy emphasis on Medicare Advantage.
• Extremely AI-forward and passionate about applying LLMs to drive operational precision in research and monitoring.
• Medicare expert with proven ability to interpret and operationalize complex clinical policies, NCDs, and LCDs.
• Experience managing vendor relationships at a strategic level with rigorous performance standards.
• Coding certifications such as CPC, CCS, COC, or CIC preferred.
• Data-focused professional who builds strategy from dashboards and trend analysis.

Responsibilities

• Own development and maintenance of clinical and reimbursement policies aligned with CMS regulations.
• Interpret and operationalize NCDs, LCDs, and national coding guidelines as a Medicare Regulatory SME.
• Oversee external vendor performance for policy monitoring and accuracy with data-driven reviews.
• Lead AI initiatives to automate monitoring of reimbursement policies using tools like Claude, Gemini, and ChatGPT.
• Collaborate with Configuration and Data Science teams to synchronize policy intent with adjudication.
• Bridge Clinical, Claims, and Compliance teams to unify payment excellence.

Skills

Medicare regulations

Policy lifecycle

Vendor management

AI/LLMs

Cross-functional collaboration

Tools

Claude

Gemini

ChatGPT

Job description

Clover Health is seeking an AI-forward Business Analyst, Clinical & Reimbursement Policy to translate Medicare guidelines into actionable policy logic for Clover’s claims environment. Remote-USA position requiring deep expertise in CMS regulations and policy lifecycle.

You will lead AI initiatives, work with external vendors, and collaborate across Clinical, Claims, and Compliance to ensure precise, automated policy operation and mentorship of the policy library to meet regulatory standards and