Content Innovation, Claims Editing
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Job Description
Claims editing expert building validated coding content for Machinify’s AI-powered healthcare payment integrity platform. Partnering with Product and Data Science to improve accuracy, savings, and client outcomes.
Responsibilities:
- Monitor and interpret authoritative sources including CPT and HCPCS updates, ICD-10-CM guidelines, NCCI PTP and MUE tables, CMS manuals, NCDs and LCDs, specialty society guidance, and payer reimbursement policies
- Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic
- Document the source, rationale, and scope of every edit
- Separate portable market-wide content from client-specific policy
- Maintain content through code updates, policy changes, and performance reviews; recommend refinements or retirement
- Use claims data to test editing concepts, size opportunities, and estimate hit rate, false-positive rate, and savings
- Review edit output and production results to identify gaps, over-reach, and missed opportunities
- Track accuracy, hit rate, false positives, appeals, overturns, provider abrasion, and realized savings
- Partner with Product, Engineering, and Data Science on requirements, logic specifications, and test cases
- Help data scientists understand clinical and coding context
- Evaluate AI tools, including large language models, for research, discovery, authoring, and quality review
- Apply expert judgment to AI-generated content and define review standards
- Explain content rationale, sources, and expected impact to clients and internal audiences
- Support client policy review, edit approval, and appeals
- Bring client feedback and operational findings into the content roadmap
- Learn Machinify’s content portfolio, source library, technology, and development process
- Own a content domain end to end 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 primary content, including 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 to test hypotheses and measure results
- 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
- Sound judgment and comfort working in a fast-moving build-and-scale environment
- Experience at a claims editing, Payment Integrity, or healthcare technology company preferred
- Experience across commercial, Medicare Advantage, and Medicaid lines of business preferred
- Clinical background with direct patient care experience preferred
- Experience writing product requirements or logic specifications preferred
- Experience with Python, SQL, or BI tools for claims analysis preferred
- Experience presenting content rationale or savings analyses to health plan clients preferred
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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