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 – Machinify (Remote, US)
Develop and validate coding content for Machinify’s AI-powered healthcare payment integrity platform. Work with Product and Data Science to improve editing accuracy, savings, and client outcomes.
Aprašymas
- Research authoritative coding and reimbursement sources, including CPT and HCPCS updates, ICD-10-CM guidelines, NCCI tables, CMS materials, specialty guidance, and payer policies.
- Convert coding rules, clinical guidance, and reimbursement policies into precise, testable edit logic.
- Record each edit’s sources, rationale, and scope.
- Distinguish broadly applicable content from policies specific to individual clients.
- Update content as codes, policies, and performance change, recommending revisions or retirement when appropriate.
- Analyze claims data to test editing concepts, assess opportunities, and estimate hit rates, false positives, and savings.
- Examine edit outputs and production results to find gaps, excessive edits, and missed opportunities.
- Monitor accuracy, hit rates, false positives, appeals, overturns, provider abrasion, and realized savings.
- Work with Product, Engineering, and Data Science on requirements, logic specifications, and test cases.
- Give data scientists the clinical and coding context needed for their work.
- Assess AI tools, including large language models, for research, discovery, content creation, and quality review.
- Use expert judgment to assess AI-generated content and establish review standards.
- Explain content rationale, evidence, and expected impact to clients and colleagues.
- Assist with client policy reviews, edit approvals, and appeals.
- Bring client feedback and operational insights into content roadmap planning.
- Build knowledge of Machinify’s content portfolio, source library, technology, and development process.
- Lead a content area from research through production, advancing concepts validated with data.
Reikalavimai
- At least 7 years of experience in claims editing, clinical coding, payment integrity, or payer policy, including hands-on edit authoring or validation.
- An active coding credential such as CPC, CCS, CCS-P, CPMA, or CIC, or an RN or other clinical license combined with substantial coding experience.
- Current, in-depth knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation requirements.
- Working knowledge of reimbursement methods such as fee schedules, DRGs, APCs, and professional and facility billing.
- Experience locating and interpreting primary sources, including CMS manuals, NCDs and LCDs, AMA guidance, and payer policies.
- Strong analytical ability and experience using claims data and SQL, Excel, or similar tools to test hypotheses and measure outcomes.
- Experience collaborating with Product, Engineering, Data Science, or other cross-functional teams.
- Clear writing skills and the ability to explain complex clinical and coding logic to nonclinical audiences.
- Interest in AI tools and willingness to use them in routine content work.
- Sound judgment and comfort working in a fast-paced, growing environment.
- Experience with a claims editing, payment integrity, or healthcare technology company preferred.
- Experience with commercial, Medicare Advantage, and Medicaid lines of business preferred.
- Clinical background that includes direct patient care preferred.
- Experience writing product requirements or logic specifications preferred.
- Experience using Python, SQL, or business intelligence tools for claims analysis preferred.
- Experience presenting content rationale or savings analyses to health plan clients preferred.
Privalumai
- Paid time off, holidays, and volunteer days.
- Eligibility for health, vision, and dental coverage.
- Participation in a 401(k) plan with company matching.
- Flexible spending accounts.
- Tuition reimbursement.
- Company-paid life insurance.
- Company-paid short-term disability coverage.
- Company-paid parental leave.
- Remote and hybrid work options.