Business Analyst, Clinical & Reimbursement Policy
New
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 5+ years
- Required Skills
- Artificial IntelligenceData Analysis
Requirements
- 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.
Responsibilities
- 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.
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