Business Analyst, Clinical & Reimbursement Policy

Clover Health is hiring a Business Analyst, Clinical & Reimbursement Policy to manage the lifecycle of its clinical and reimbursement policies and ensure alignment with Medicare regulations. The role translates Medicare guidance into operational claims logic, oversees vendors, and partners with technical and cross-functional teams to improve policy monitoring and adjudication accuracy.

Responsibilities:

• Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations
• Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and general national coding guidelines
• 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
• 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
• Partner with the Configuration and Data Science teams to ensure that clinical and reimbursement policy intent is perfectly synchronized with technical adjudication
• Act as the strategic bridge between Clinical, Claims, and Compliance teams to ensure a unified vision of payment excellence

Requirements:

• 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
• 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
• coding certifications such as CPC, CCS, COC, or CIC