Business Analyst, Clinical & Reimbursement Policy Full Time NEW

This is a high-impact healthcare analytics role focused on translating complex Medicare Advantage regulations into precise, operational reimbursement and clinical policies.

You will act as a key subject matter expert, ensuring that national and local coverage determinations are accurately interpreted and embedded into claims adjudication systems.

The role sits at the intersection of healthcare policy, data, and technology, enabling a more automated and accurate payment ecosystem.

You will collaborate closely with clinical, compliance, configuration, and data teams to ensure policy intent is consistently reflected in system execution.

A strong emphasis is placed on leveraging AI and modern analytical tools to improve monitoring, research, and regulatory tracking.

This position requires both strategic thinking and hands-on execution to manage the full lifecycle of reimbursement policies.

You will play a central role in shaping scalable, data-driven healthcare operations that directly impact member care and payment accuracy.

Accountabilities

Own the development, maintenance, and operational accuracy of clinical and reimbursement policies, ensuring alignment with Medicare Advantage and CMS regulations.

• Interpret and operationalize complex Medicare guidelines, including NCDs, LCDs, and national coding standards.
• Manage the full policy lifecycle, including updates, reviews, implementation, and compliance validation.
• Partner with configuration and data teams to ensure accurate translation of policy intent into claims adjudication systems.
• Conduct regular policy audits and reviews to ensure ongoing regulatory alignment and accuracy.
• Serve as a key liaison between clinical, claims, and compliance teams to ensure consistent policy execution.
• Oversee external vendor performance related to policy monitoring, ensuring accuracy and accountability.
• Develop and implement AI-driven workflows for policy monitoring, research, and trend analysis.
• Leverage advanced tools (e.g., LLMs) to track regulatory changes and support proactive decision-making.
• Support continuous improvement of reimbursement systems through data-driven insights and operational enhancements.

Requirements

The ideal candidate brings strong Medicare Advantage expertise combined with analytical, operational, and technology-driven capabilities in healthcare reimbursement environments.

• 5+ years of experience in healthcare claims, reimbursement policy, or configuration, with strong Medicare Advantage exposure.
• Deep knowledge of CMS regulations and Medicare guidelines, including NCDs, LCDs, and coding standards.
• Experience working with claims adjudication systems or reimbursement configuration processes.
• Strong analytical and data interpretation skills, with experience using dashboards or reporting tools.
• Proven ability to manage external vendors and ensure performance against defined standards.
• Familiarity with healthcare coding certifications such as CPC, CCS, COC, or CIC is preferred.
• Experience using AI/LLM tools (e.g., ChatGPT, Claude, Gemini) for research, monitoring, or workflow optimization.
• Strong communication skills with the ability to translate complex regulatory content into operational logic.
• Detail-oriented, structured thinker with strong ownership and execution capabilities.

Benefits

• Competitive base salary with performance-based compensation structure
• Comprehensive medical, dental, and vision insurance coverage
• Flexible remote-first work environment across the United States
• Generous paid time off and flexible holiday structure
• 401(k) retirement plan with employer matching
• Paid parental leave for all family types
• Mental health support and wellness resources
• Annual learning and professional development support
• Equity opportunities and long-term incentive programs
• Home office support and monthly technology stipends
• Strong focus on work-life balance, including flexible scheduling options

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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