Business Analyst, Clinical & Reimbursement Policy

🔥 28 minutes ago

🇺🇸 United States – Remote

💵 $107k - $130k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Business Analyst

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• Own development and maintenance of clinical and reimbursement policies aligned with CMS regulations • Interpret and operationalize Medicare guidelines, including NCDs, LCDs, and national coding guidelines • Oversee external vendor performance for policy monitoring and accuracy • Conduct data-driven vendor performance reviews and design collaborative workflows • Lead AI initiatives to automate reimbursement policy monitoring • Use Claude, Gemini, and ChatGPT for deep research on industry trends • Partner with Configuration and Data Science teams to synchronize policy intent with technical adjudication • Bridge Clinical, Claims, and Compliance teams around payment excellence • Establish a recurring review framework and project plan for the policy library • Keep policies current with regulatory requirements • Implement AI-forward oversight and early-detection monitoring frameworks

🎯 Requirements

• 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with heavy emphasis on Medicare Advantage • AI-forward mindset and passion for applying emerging technologies and LLMs to research and monitoring • Medicare expertise interpreting and operationalizing complex clinical policies, NCDs, and LCDs • Proven experience managing strategic vendor relationships and enforcing rigorous performance standards • Data-focused approach using dashboards and trend analysis • Familiarity with enterprise claims engines and their role in adjudication accuracy • Coding certifications such as CPC, CCS, COC, or CIC are preferred qualifications

🏖️ Benefits

• Competitive base salary • Equity opportunities • Performance-based bonus program • 401k matching • Regular compensation reviews • Comprehensive medical, dental, and vision coverage • No-Meeting Fridays • Monthly company holidays • Mental health resources • Generous flexible time-off policy • Remote-first culture • Learning programs • Mentorship • Professional development funding • Regular performance feedback and reviews • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Collaboration with global teams • Paid parental leave for all new parents