Business Analyst, Clinical & Reimbursement Policy

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Business Analyst, Clinical & Reimbursement Policy based in the United States.

The Business Analyst, Clinical & Reimbursement Policy will help transform complex healthcare regulations into accurate, automated, and scalable claims processes. This remote role combines deep Medicare Advantage expertise, policy management, data analysis, and emerging AI technologies to strengthen payment accuracy and regulatory compliance. You will oversee the full lifecycle of clinical and reimbursement policies, ensuring they remain current, correctly interpreted, and consistently implemented across claims systems. Acting as a subject matter expert, you will collaborate with Clinical, Claims, Compliance, Configuration, and Data Science teams to translate regulatory guidance into actionable technical requirements. You will also manage external vendor performance and leverage advanced AI tools to automate policy monitoring and regulatory research. This opportunity is ideal for a detail-oriented, forward-thinking professional passionate about improving healthcare operations through technology, automation, and data-driven decision-making.

As a Business Analyst, Clinical & Reimbursement Policy, you will oversee policy accuracy, regulatory alignment, vendor performance, and the adoption of AI-driven processes. Your key responsibilities will include:

• Manage the full lifecycle of clinical and reimbursement policies, including development, maintenance, review, and updates, ensuring alignment with applicable Centers for Medicare & Medicaid Services (CMS) regulations.

• Serve as a subject matter expert on Medicare guidelines, interpreting and operationalizing National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and national coding guidelines.

• Establish a structured policy review framework and maintain a comprehensive project plan to ensure consistent quality and regulatory compliance.

• Ensure all existing clinical and reimbursement policies remain accurate and current as regulations and industry requirements evolve.

• Lead initiatives to automate reimbursement policy monitoring using AI technologies and advanced research tools.

• Use large language models (LLMs), including ChatGPT, Claude, and Gemini, to conduct in-depth research, identify industry trends, and monitor regulatory developments.

• Develop proactive monitoring and early-detection processes to identify policy changes and potential issues before they affect claims adjudication.

• Manage external vendor relationships and oversee performance related to policy monitoring, research, and accuracy.

• Conduct data-driven vendor performance reviews, establish rigorous quality expectations, and collaborate with external partners to improve workflows.

• Partner with Configuration and Data Science teams to ensure policy requirements are accurately translated into technical rules and reflected in claims adjudication systems.

• Collaborate with Clinical, Claims, and Compliance teams to align policy interpretation, operational execution, and payment accuracy.

• Analyze dashboards, performance indicators, and emerging trends to identify risks, measure policy effectiveness, and inform strategic decisions.

• Drive continuous improvement in policy management, strengthening automation, operational precision, and the reliability of the reimbursement process.

• Establish measurable milestones for policy quality, regulatory compliance, automated monitoring, and the ongoing optimization of claims operations.

Requirements:

The ideal candidate combines extensive healthcare claims or reimbursement policy experience with strong Medicare Advantage knowledge, analytical skills, vendor management capabilities, and enthusiasm for AI-driven innovation. Required and preferred qualifications include:

• At least 5 years of experience in healthcare claims, configuration, or reimbursement policy, with a strong emphasis on Medicare Advantage.

• Extensive knowledge of Medicare regulations and the ability to interpret and operationalize complex clinical policies, NCDs, LCDs, and national coding guidelines.

• A demonstrated ability to manage clinical and reimbursement policy lifecycles and maintain alignment with evolving regulatory requirements.

• Strong interest in AI technologies and practical experience or enthusiasm for using LLMs such as ChatGPT, Claude, and Gemini to improve research, monitoring, and operational workflows.

• Experience managing external vendors or strategic partners, monitoring performance, and ensuring compliance with demanding accuracy and quality standards.

• Strong analytical skills, including the ability to interpret dashboards, evaluate trends, and develop data-driven recommendations.

• Familiarity with enterprise claims engines and an understanding of how configuration rules and policy requirements influence claims adjudication accuracy.

• Ability to translate complex regulatory and business requirements into clear, actionable functional specifications.

• Strong collaboration and communication skills, with the ability to work effectively across Clinical, Claims, Compliance, Configuration, Data Science, and external vendor teams.

• A proactive, detail-oriented approach to problem-solving, process improvement, and regulatory research.

• Professional coding certification, such as Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Outpatient Coder (COC), or Certified Inpatient Coder (CIC), is preferred.

Benefits:

• Annual base salary ranging from $107,000 to $130,000 USD.

• Equity opportunities and a performance-based bonus program.

• 401(k) retirement plan with company matching.

• Regular compensation reviews.

• Comprehensive medical, dental, and vision insurance.

• Remote-first work culture that supports flexibility and collaboration.

• Flexible paid time off.

• No-Meeting Fridays to support focused work and productivity.

• Monthly company holidays.

• Access to mental health resources and initiatives supporting employee well-being.

• Professional development programs, learning opportunities, mentorship, and development funding.

• Regular performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) with discounted equity opportunities.

• Reimbursement for home office setup expenses.

• Monthly cell phone and internet stipend.

• Paid parental leave for all new parents.

• Additional programs and resources designed to support financial, physical, and mental well-being.

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

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