Business Analyst, Clinical & Reimbursement Policy
Accountabilities: The Business Analyst, Clinical & Reimbursement Policy will oversee the development, optimization, and operationalization of healthcare policies while ensuring alignment with regulatory requirements and business objectives.
Own the end-to-end lifecycle of clinical and reimbursement policies, ensuring accuracy, compliance, and alignment with applicable healthcare regulations.
Serve as a Medicare regulatory subject matter expert, interpreting and translating National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and coding guidelines into actionable business logic.
Partner with internal teams to ensure clinical and reimbursement policy intent is accurately reflected within claims configuration and adjudication systems.
Manage external vendor relationships, monitoring performance, ensuring policy accuracy, and driving continuous improvements through structured reviews and collaboration.
Lead AI-driven initiatives to automate policy monitoring, research, and regulatory tracking using advanced AI and large language model tools.
Conduct ongoing research on industry trends, regulatory updates, and reimbursement changes to proactively identify opportunities and risks.
Collaborate with clinical, claims, compliance, data science, and configuration teams to create consistent and effective payment strategies.
Develop dashboards, reporting frameworks, and analytical insights to support data-driven decision-making.
Establish scalable policy governance processes and continuously improve operational precision.
Act as a strategic advisor who helps teams navigate complex healthcare requirements while enabling innovation and growth.
Requirements:
The ideal candidate is a healthcare-focused business analyst with strong Medicare expertise, analytical capabilities, and a passion for using technology to improve operational outcomes.
5+ years of experience in healthcare claims, configuration, reimbursement policy, or related healthcare operations, with significant Medicare Advantage experience.
Deep knowledge of Medicare regulations, clinical policies, reimbursement guidelines, NCDs, LCDs, and coding requirements.
Experience translating complex regulatory requirements into practical operational workflows and system logic.
Strong interest in AI-driven solutions and hands-on experience using AI/LLM tools such as ChatGPT, Claude, or Gemini for research, automation, or operational improvements.
Experience managing external vendors or strategic partners, with the ability to evaluate performance and drive accountability.
Familiarity with enterprise claims engines and understanding of how technical systems support claims adjudication accuracy.
Strong analytical skills with experience using dashboards, trend analysis, and data insights to guide strategy.
Preferred certifications include CPC, CCS, COC, or CIC coding credentials.
Ability to work cross-functionally and communicate effectively with technical, clinical, operational, and compliance stakeholders.
Detail-oriented, proactive, and comfortable operating in an evolving environment where regulatory accuracy and innovation are critical.
Benefits:
Competitive annual base salary range of $107,000–$130,000 USD, depending on experience, location, education, certifications, and other relevant factors.
Equity opportunities and performance-based bonus eligibility.
401(k) matching program.
Comprehensive medical, dental, and vision coverage.
Flexible time-off policy and paid company holidays.
Remote-first work environment with flexibility to collaborate from anywhere.
No-Meeting Fridays to support focus, productivity, and work-life balance.
Access to mental health resources and employee wellness initiatives.
Professional development programs, mentorship opportunities, and learning resources.
Employee Stock Purchase Plan (ESPP) with discounted equity opportunities.
Office setup reimbursement and monthly phone and internet stipend.
Paid parental leave for all new parents.
Opportunity to contribute to innovative healthcare solutions focused on improving patient outcomes and operational efficiency.
How Jobgether works: 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! Why Apply Through Jobgether?
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