Content Innovation, Claims Editing

This is a fully remote position, open to applicants in United States.

📋 Description

• Monitor and analyze authoritative sources such as CPT and HCPCS updates, ICD-10-CM guidelines, NCCI PTP and MUE tables, CMS manuals, NCDs and LCDs, specialty society recommendations, and payer reimbursement policies.

• Convert coding regulations, clinical guidelines, and reimbursement policies into accurate, testable editing logic.

• Record the source, rationale, and scope of each edit.

• Distinguish between portable market-wide content and client-specific policies.

• Maintain content in accordance with code updates, policy adjustments, and performance evaluations; suggest enhancements or discontinuation as necessary.

• Utilize claims data to validate editing concepts, assess opportunities, and estimate hit rates, false-positive rates, and potential savings.

• Analyze edit outputs and production results to identify discrepancies, overreach, and missed opportunities.

• Monitor accuracy, hit rates, false positives, appeals, overturns, provider abrasion, and realized savings.

• Collaborate with Product, Engineering, and Data Science teams on requirements, logic specifications, and test cases.

• Assist data scientists in grasping clinical and coding contexts.

• Assess AI tools, including large language models, for research, discovery, content creation, and quality review.

• Apply expert judgment to content generated by AI and establish review standards.

• Communicate the rationale, sources, and anticipated impact of content to clients and internal stakeholders.

• Facilitate client policy evaluations, edit approvals, and appeals processes.

• Incorporate client feedback and operational insights into the content roadmap.

• Familiarize yourself with Machinify’s content portfolio, source library, technology, and development processes.

• Own a content domain from beginning to end and transition data-validated concepts into production.

⛳️ Requirements

• Over 7 years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with practical experience in authoring or validating edits.

• Active coding credential such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license such as RN along with extensive coding experience.

• Comprehensive and up-to-date knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding standards, and documentation requirements.

• Familiarity with reimbursement methodologies, including fee schedules, DRGs, APCs, and both professional and facility billing.

• Experience in sourcing and interpreting primary content, including CMS manuals, NCDs and LCDs, AMA guidance, and payer policies.

• Strong analytical abilities and confidence in working with claims data, utilizing SQL, Excel, or similar tools to test hypotheses and evaluate results.

• Experience collaborating with Product, Engineering, Data Science, or other interdisciplinary teams.

• Proficient written communication skills and the ability to clarify complex coding and clinical logic to nonclinical audiences.

• An interest in AI tools and a willingness to integrate them into daily content tasks.

• Good judgment and adaptability in a dynamic build-and-scale environment.

• Experience in a claims editing, Payment Integrity, or healthcare technology setting is preferred.

• Experience across commercial, Medicare Advantage, and Medicaid lines of business is preferred.

• A clinical background with direct patient care experience is preferred.

• Experience in drafting product requirements or logic specifications is preferred.

• Familiarity with Python, SQL, or BI tools for claims analysis is preferred.

• Experience presenting content rationale or savings analyses to health plan clients is preferred.

🏝️ Benefits

• PTO, Paid Holidays, and Volunteer Days.

• Eligibility for health, vision, and dental coverage.

• Participation in a 401(k) plan with company match.

• Flexible spending accounts.

• Tuition Reimbursement.

• Company-paid life insurance.

• Company-paid short-term disability.

• Company-paid parental leave.

• Options for remote and hybrid work.