Business Analyst, Clinical & Reimbursement Policy

Responsibilities

• 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.
• 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.
• 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 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.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.

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