Content Innovation, Claims Editing
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Job Description
Claims editing expert building evidence-based New York Medicaid content for Machinify, a healthcare intelligence company. Validating edits with claims data and partnering with Product, Engineering, and Data Science.
Responsibilities:
- Monitor and interpret CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, payer, and New York Medicaid sources
- Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic
- Document edit sources, rationale, and scope for traceability and appeals
- Separate portable market-wide content from client-specific policy
- Maintain content through code updates, policy changes, and performance reviews
- Build New York Medicaid content for Mainstream Managed Care, HARP, behavioral health, FQHC, and long-term care services
- Use claims data to test concepts, size opportunities, and estimate hit rates, false positives, and savings
- Review production results and track accuracy, appeals, overturns, provider abrasion, and realized savings
- Partner with Product, Engineering, and Data Science on requirements, logic specifications, test cases, and AI-assisted content workflows
- Explain content rationale and impact to clients and internal teams; support policy review, approvals, and appeals
- In the first 90 days, learn the content portfolio and deliver a prioritized list of New York content gaps and opportunities
- Within 6–12 months, own a content domain, move data-validated concepts into production, maintain documentation, improve content-building processes, and demonstrate measurable results
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 experience with New York State Medicaid policy, billing, or Payment Integrity, including eMedNY, APGs, APR-DRGs, and NYS DOH and OMIG guidance
- 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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