Business Analyst, Clinical & Reimbursement Policy

This is a fully remote position, open to applicants in United States.

📋 Description

• Take charge of the development and upkeep of clinical and reimbursement policies in accordance with CMS regulations.

• Analyze and implement Medicare guidelines, which include NCDs, LCDs, and national coding standards.

• Manage the performance of external vendors to ensure policy monitoring and accuracy.

• Perform data-driven evaluations of vendor performance and create collaborative workflows.

• Spearhead AI initiatives aimed at automating the monitoring of reimbursement policies.

• Utilize Claude, Gemini, and ChatGPT for in-depth research on industry trends.

• Collaborate with the Configuration and Data Science teams to align policy objectives with technical adjudication.

• Connect Clinical, Claims, and Compliance teams to achieve payment excellence.

• Develop a recurring review framework and a project plan for the policy library.

• Ensure that policies remain up-to-date with regulatory requirements.

• Establish AI-driven oversight and early-detection monitoring systems.

⛳️ Requirements

• A minimum of 5 years of experience in healthcare claims, configuration, or reimbursement policy, with a strong focus on Medicare Advantage.

• An AI-focused mindset and enthusiasm for leveraging emerging technologies and LLMs for research and monitoring.

• Expertise in Medicare, particularly in interpreting and implementing complex clinical policies, NCDs, and LCDs.

• Proven ability to manage strategic vendor relationships while upholding strict performance standards.

• A data-centric approach that utilizes dashboards and trend analysis.

• Knowledge of enterprise claims engines and their significance in adjudication accuracy.

• Coding certifications such as CPC, CCS, COC, or CIC are preferred qualifications.

🏝️ Benefits

• Competitive base salary

• Equity opportunities

• Performance-based bonus program

• 401k matching

• Regular compensation reviews

• Comprehensive medical, dental, and vision coverage

• No-Meeting Fridays

• Monthly company holidays

• Mental health resources

• Generous flexible time-off policy

• Remote-first culture

• Learning programs

• Mentorship

• Professional development funding

• Regular performance feedback and reviews

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities

• Reimbursement for office setup expenses

• Monthly cell phone & internet stipend

• Collaboration with global teams

• Paid parental leave for all new parents