Business Analyst - Clinical Coverage

Agadia Systems Inc•Parsippany-Troy Hills, NJ

8h•$115,000 - $150,000•Remote

About The Position

We’re an early-stage healthcare team looking for a clinically trained coverage analyst with deep knowledge of how specialty medications are covered under medical and pharmacy benefits. You’ll apply your clinical and managed-care expertise to interpret payer coverage and support the team’s work on patient access. This is a hands-on, individual-contributor role on a small team — a good fit for someone who likes ownership, variety, and working close to the detail rather than managing others.

Requirements

3+ years as a business analyst, clinical analyst, or coverage/policy analyst in specialty pharmacy, benefit investigation, market access, payer, PBM, or a hub/patient-access services environment.
Demonstrated fluency in medical-benefit coverage: J-code/HCPCS, medical policy interpretation, utilization management, step therapy, prior authorization, and delegated UM vendors.
Working understanding of the pharmacy vs. medical benefit distinction and why specialty drugs route to one or the other.
Experience translating unstructured policy language into structured, rule-based logic or decision tables.
Rigorous, source-driven approach — comfortable citing sources, versioning criteria, and defending accuracy.
Strong written specification skills; able to hand a build team requirements they can implement without ambiguity.

Nice To Haves

Clinical background or credential (PharmD, RN, pharmacy technician with UM experience, or equivalent coverage-review experience).
Familiarity with eligibility transactions (X12 270/271), pharmacy discovery (NCPDP E1 / card discovery), RTBC/RTPB, and Transparency-in-Coverage data.
Exposure to prior-authorization automation, CDS Hooks / SMART-on-FHIR, or FHIR-based coverage APIs (Da Vinci CRD/DTR/PAS, CMS interoperability rules).
Experience building or maintaining a payer-policy knowledge base, formulary database, or coverage rules repository.

Responsibilities

Interpret payer coverage. Review medical and pharmacy benefit policies and clinical guidelines to understand coverage requirements for specialty medications.
Apply clinical judgment. Assess coverage criteria such as diagnosis and indication requirements, step therapy, and prior-authorization requirements.
Document clearly. Summarize coverage findings in clear, well-organized, well-sourced manner to create product and technical requirements.
Stay current. Track changes in payer policies and clinical guidelines and regularly update the requirements.
Collaborate cross-functionally. Work closely with colleagues across the team, and with technical development colleagues.
Hold a high bar. Bring rigor and attention to detail — cite your sources, double-check your work, and flag anything unclear.