Machinify yra sveikatos priežiūros dirbtinio intelekto platforma ir paslaugų įmonė, siekianti gerinti sveikatos draudimo planų mokėjimų tikslumą. Jos dirbtinio intelekto operacinė sistema sujungia žalų paraiškas, medicininius įrašus, sutartis ir taisykles, o pamatinius modelius derina su konkrečioms užduotims skirtais agentais, kad padėtų koduoti duomenis, užtikrinti mokėjimų tikslumą, susigrąžinti lėšas ir išvengti išlaidų. Machinify siūlo vidinį, hibridinį ir visiškai valdomą diegimą, aptarnauja daugiau kaip 85 klientus, kurių planai apima 270 milijonų narių. Įmonė skelbia kasmet padedanti išvengti išlaidų ir susigrąžinti daugiau kaip 6 milijardus JAV dolerių.
Senior Claims Editing Content Specialist
Develop evidence-based New York Medicaid claims content for Machinify, validating edits against claims data. Collaborate with Product, Engineering, and Data Science to improve editing logic and workflows.
Aprašymas
- Track coding, payer, and New York Medicaid guidance to inform claims edits
- Turn coding rules, clinical guidance, and reimbursement policies into precise, testable edit logic
- Record sources, rationale, and scope to support traceability and appeals
- Distinguish broadly applicable content from client-specific policy
- Update content as codes and policies change, and as performance is reviewed
- Create New York Medicaid content spanning managed care, HARP, behavioral health, FQHC, and long-term care
- Analyze claims data to test ideas, assess opportunities, and estimate hit rates, false positives, and savings
- Assess production outcomes, monitoring accuracy, appeals, overturned edits, provider friction, and realized savings
- Work with Product, Engineering, and Data Science to define requirements, logic, test cases, and AI-supported content workflows
- Communicate the rationale and impact of content to clients and internal teams, supporting policy reviews, approvals, and appeals
- During the first 90 days, learn the content portfolio and prioritize New York content gaps and opportunities
- Within 6–12 months, take ownership of a content area, bring data-validated concepts into production, maintain documentation, improve authoring processes, and show measurable outcomes
Reikalavimai
- Bring at least seven years of experience in claims editing, clinical coding, payment integrity, or payer policy, including hands-on edit creation or validation
- Hold an active coding credential such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license such as RN combined with substantial coding experience
- Have current, in-depth knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidance, and documentation standards
- Understand reimbursement approaches, including fee schedules, DRGs, APCs, and professional and facility billing
- Have experience finding and interpreting CMS manuals, NCDs and LCDs, AMA guidance, and payer policies
- Be analytically strong and comfortable using SQL, Excel, or comparable tools to work with claims data
- Have collaborated with Product, Engineering, Data Science, or other cross-functional teams
- Communicate clearly in writing and explain complex coding and clinical reasoning to nonclinical audiences
- Be curious about AI tools and willing to incorporate them into day-to-day content work
- Have at least three years of experience with New York State Medicaid policy, billing, or payment integrity, including eMedNY, APGs, APR-DRGs, and NYS DOH and OMIG guidance
- Exercise sound judgment and work comfortably in a fast-paced, scaling environment
Privalumai
- Paid time off, holidays, and volunteer days
- Eligible for health, vision, and dental coverage
- 401(k) participation with an employer match
- Flexible spending accounts
- Tuition reimbursement
- Company-paid life insurance
- Company-paid short-term disability coverage
- Company-paid parental leave
- Remote and hybrid work options