Content Innovation, Claims Editing – Specialty Pharmacy (Multiple Levels)

Machinify

1d • $135,000 - $165,000

About The Position

Machinify is seeking a claims-editing content expert to build the next generation of editing content, with a focus on specialty pharmacy and high-cost drugs billed under the medical benefit. The role sources, designs, validates, and maintains the clinical and coding content that powers editing products. It identifies opportunities in policy and claims data, turns them into defensible edits, and measures their value for health plan clients.

This build-and-scale position sits at the intersection of clinical editing, coding, reimbursement policy, data science, and product development. The role requires deep clinical editing and coding expertise, analytical thinking, and practical interest in using AI to build content efficiently while maintaining quality and clinical accuracy. The successful candidate does not need to be a data scientist but should evaluate evidence, measurable outcomes, and client value.

The position’s work includes interpreting authoritative coding, clinical, drug, and reimbursement sources; creating and maintaining testable editing logic; documenting sources and rationale; analyzing claims data and production results; collaborating with Product, Engineering, and Data Science; assessing AI-generated content; and explaining editing content and its impact to clients and internal teams.

This is an exempt position. The base salary range is $135,000–$165,000 USD, with compensation determined by factors including skill set, experience, and geographic location. Remote and hybrid work options are offered.

Requirements

• At least 7 years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, including hands-on experience authoring or validating edits.
• An 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.
• At least 3 years of hands-on experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement.
• Sound judgment and comfort working in a fast-moving build-and-scale environment.

Nice To Haves

• Pharmacy background, such as PharmD, RPh, or CPhT, or experience in specialty pharmacy, infusion, or oncology practice billing.
• Experience with 340B billing rules, biosimilar adoption, or oncology drug policy.
• Experience at a claims editing, Payment Integrity, or healthcare technology company.
• Experience across commercial, Medicare Advantage, and Medicaid lines of business.
• Clinical background (RN, LPN, or other licensed clinician) with direct patient care experience.
• Experience writing product requirements or logic specifications for engineering teams.
• Experience with Python, SQL, or BI tools for claims analysis.
• Experience presenting content rationale or savings analyses to health plan clients.

Responsibilities

• Monitor and interpret authoritative coding, clinical, drug, and reimbursement sources, including CPT and HCPCS updates, ICD-10-CM guidelines, NCCI PTP and MUE tables, CMS manuals, NCDs and LCDs, specialty society guidance, payer policies, FDA prescribing information, drug compendia, clinical guidelines, and CMS ASP pricing files.
• Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic.
• Document each edit’s source, rationale, and scope so it is traceable, defensible on appeal, and maintainable.
• Distinguish portable, market-wide content from client-specific policy and clearly flag the difference in content and sizing work.
• Maintain editing content through code updates, policy changes, and performance reviews; recommend refinements or retirement when appropriate.
• Build and maintain drug edits for HCPCS billing units, NDC-to-HCPCS crosswalks, weight- and BSA-based dosing, maximum units, dose rounding, and JW and JZ drug wastage modifiers.
• Cover oncology, immunology, rare disease, biosimilars, and other high-cost therapeutic areas, including new drug launches and HCPCS codes.
• Track label changes, new approvals, quarterly HCPCS updates, and pricing changes to keep drug content current.
• Use claims data to test editing concepts, size opportunities, and estimate hit rates, false-positive rates, and savings.
• Review edit output and production results to verify edits perform as intended and identify gaps, over-reach, and missed opportunities.
• Track measures including accuracy, hit rate, false positives, appeals, overturns, provider abrasion, and realized savings.
• Prioritize work using opportunity, confidence, and expected client return.
• Work with Product, Engineering, and Data Science to turn content concepts into requirements, logic specifications, and test cases.
• Explain clinical and coding context, including drug dosing, units, and billing, to data scientists working on models and analyses.
• Evaluate AI tools, including large language models, for policy research, concept discovery, content authoring, and quality review; apply expert judgment to AI-generated content and help define review standards.
• Explain the rationale, sources, and expected impact of editing content to client and internal audiences.
• Support client policy review, edit approval, and appeals with clear, well-sourced documentation.
• Incorporate client feedback and operational findings into the content roadmap.
• During the first 90 days, learn the content portfolio, source library, technology, and development process; build relationships with Product and Data Science; assess drug editing coverage; and deliver a prioritized list of specialty drug content gaps and opportunities.
• Within 6 to 12 months, own a content domain end to end, move multiple data-validated concepts into production, maintain current source documentation, contribute to an AI-assisted content improvement, establish a repeatable process for tracking new approvals, label changes, and HCPCS updates, and demonstrate measurable results in edit accuracy, speed, or client value.

Benefits

• PTO, paid holidays, and volunteer days.
• Eligibility for health, vision, and dental coverage.
• Eligibility to participate in a 401(k) plan with company match.
• Flexible spending accounts.
• Tuition reimbursement.
• Eligibility for company-paid life insurance, short-term disability, and parental leave.
• Remote and hybrid work options.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed