Content Innovation, Claims Editing – Specialty Pharmacy
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Job Description
Claims editing expert building specialty pharmacy and high-cost drug content for Machinify’s healthcare intelligence platform. Validating edits with claims data and partnering with Product and Data Science.
Responsibilities:
- Monitor and interpret CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, FDA, drug compendia, NCCN, pricing, and payer policy sources
- Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic
- Document edit sources, rationale, and scope for traceability and appeals
- Maintain content through code updates, policy changes, and performance reviews
- Build and maintain specialty drug edits for billing units, NDC-to-HCPCS crosswalks, dosing, maximum units, dose rounding, and JW/JZ modifiers
- Cover oncology, immunology, rare disease, biosimilars, and other high-cost therapeutic areas
- Use claims data to test concepts, size opportunities, and measure hit rates, false positives, and savings
- Review production results to identify gaps, overreach, and missed opportunities
- Partner with Product, Engineering, and Data Science on requirements, logic specifications, test cases, and clinical context
- Evaluate AI tools and apply expert judgment to AI-generated content
- Support client policy review, edit approval, appeals, and content roadmap improvements
- Own a content domain and move data-validated concepts into production
Requirements:
- 7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with hands-on experience authoring or validating edits
- Active coding credential, such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license such as RN paired with deep coding experience
- Deep, current knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation requirements
- Working knowledge of reimbursement methodologies, including fee schedules, DRGs, APCs, and professional and facility billing
- Experience sourcing and interpreting CMS manuals, NCDs and LCDs, AMA guidance, and payer policies
- Strong analytical skills and comfort working with claims data using SQL, Excel, or similar tools
- Experience working with Product, Engineering, Data Science, or other multidisciplinary teams
- Clear written communication and ability to explain complex coding and clinical logic to nonclinical audiences
- Curiosity about AI tools and willingness to use them in daily content work
- At least 3 years of hands-on experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement
- Sound judgment and comfort working in a fast-moving build-and-scale environment
Benefits:
- PTO, Paid Holidays, and Volunteer Days
- Eligibility for health, vision and dental coverage
- 401(k) plan participation with company match
- Flexible spending accounts
- Tuition Reimbursement
- Company-paid life insurance
- Company-paid short-term disability
- Company-paid parental leave
- Remote and hybrid work options
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