Business Analyst - Clinical Coverage

Agadia is an early-stage healthcare team seeking a clinically trained coverage analyst with expertise in specialty medications. The role involves interpreting payer coverage, applying clinical judgment, and collaborating with colleagues to ensure accurate documentation and adherence to coverage requirements.

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

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
• 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