Business Analyst, Clinical & Reimbursement Policy
Operations
Excel
WFA Digital Insight
The demand for skilled business analysts in the healthcare industry has grown significantly, with a recent surge in Medicare Advantage plans. As the healthcare landscape evolves, companies like Clover Health are seeking talented professionals to navigate the complexities of clinical and reimbursement policies. With the rise of AI-driven technologies, candidates with expertise in data analysis and automation are in high demand. Clover Health stands out for its commitment to leveraging technology to improve healthcare outcomes. Before applying, candidates should be prepared to demonstrate their knowledge of Medicare guidelines and experience in policy management.
Job Description
About the Role
As a Business Analyst, Clinical & Reimbursement Policy at Clover Health, you will play a critical role in ensuring the accurate interpretation and implementation of clinical and reimbursement policies. You will serve as a strategic bridge between regulatory requirements and automated execution, working closely with cross-functional teams to drive payment excellence. The role entails developing and maintaining clinical and reimbursement policies, ensuring compliance with CMS regulations, and leveraging AI-driven technologies to automate monitoring and research. Clover Health is a Medicare Advantage plan that aims to empower its members by providing personalized, high-quality care. The company is committed to making healthcare more accessible and affordable, and as a Business Analyst, you will be an integral part of this mission. You will report to a senior manager and work closely with the Configuration and Data Science teams to ensure that clinical and reimbursement policy intent is perfectly synchronized with technical adjudication.What You Will Do
- Develop and maintain clinical and reimbursement policies, ensuring perfect alignment with CMS regulations
- Serve as the authority on Medicare guidelines, interpreting and operationalizing NCDs, LCDs, and general national coding guidelines
- Partner with external vendors to enhance policy oversight and ensure accurate implementation
- Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies
- Utilize advanced LLMs to conduct regular deep research on ongoing industry trends
- Collaborate with the Configuration and Data Science teams to ensure seamless integration of clinical and reimbursement policies
- Develop and maintain a comprehensive project plan for Clover's clinical and reimbursement policy library
- Ensure all existing clinical and reimbursement policies are current and up to date, reflecting the latest regulatory requirements
- Act as the strategic bridge between Clinical, Claims, and Compliance teams to ensure a unified vision of payment excellence
What We Are Looking For
- 5+ years of experience in healthcare claims, configuration, or reimbursement policy, with a heavy emphasis on Medicare Advantage
- Strong knowledge of Medicare guidelines, including NCDs, LCDs, and general national coding guidelines
- Experience with AI-driven technologies and data analysis tools
- Excellent communication and project management skills
- Ability to work in a fast-paced environment and prioritize multiple tasks
- Strong attention to detail and analytical skills
- Experience with Excel and other data analysis tools
Nice to Have
- Experience with AI tools like Claude, Gemini, and ChatGPT
- Knowledge of data science and machine learning concepts
- Certification in healthcare policy or a related field
Benefits and Perks
- Competitive salary and benefits package
- Opportunity to work with a leading healthcare company
- Collaborative and dynamic work environment
- Professional development and growth opportunities
- Remote work options and flexible scheduling
- Access to cutting-edge technologies and tools
- Comprehensive health insurance and wellness programs
How to Stand Out
- Be prepared to demonstrate your knowledge of Medicare guidelines and experience in policy management
- Highlight your skills in data analysis and AI-driven technologies, such as Excel and LLMs
- Show examples of your ability to work in a fast-paced environment and prioritize multiple tasks
- Emphasize your strong communication and project management skills
- Be ready to discuss your experience with clinical and reimbursement policies, and how you can contribute to Clover Health's mission
- Research the company's culture and values, and be prepared to discuss how you align with them
- Prepare examples of your experience with AI tools like Claude, Gemini, and ChatGPT
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