Business Analyst, Clinical & Reimbursement Policy

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.

• 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.

• 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.

• 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.