Content Innovation, Claims Editing - NY Medicaid (Multiple Levels)

Machinify

1d • $135,000 - $165,000

About The Position

Machinify is seeking a claims editing content expert with deep expertise in New York State Medicaid to build and maintain the clinical and coding content that powers its editing products. The role sources, designs, validates, and maintains editing content; identifies opportunities in policy and claims data; and measures the value edits deliver to health plan clients. It sits at the intersection of clinical editing, coding, reimbursement policy, data science, and product development, with an emphasis on evidence, measurable outcomes, clinical accuracy, and practical use of AI.

The position covers authoring and maintaining editing logic based on authoritative coding, clinical, and reimbursement sources; interpreting New York Medicaid policy; validating concepts and production performance with claims data; and partnering with Product, Engineering, and Data Science. The role also supports clients and internal teams by explaining edit rationale, documentation, and expected impact, and by incorporating feedback into the content roadmap.

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 combined 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 experience with New York State Medicaid policy, billing, or Payment Integrity, including working knowledge of eMedNY, APGs, APR-DRGs, and NYS DOH and OMIG guidance.
• Sound judgment and comfort working in a fast-moving build-and-scale environment.

Nice To Haves

• Experience at a New York Medicaid managed care plan, the NYS Department of Health, OMIG, or a vendor serving New York Medicaid.
• Experience with New York behavioral health, HARP, OASAS, OMH, or long-term care billing.
• 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, 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, and payer policies.
• Translate coding rules, clinical guidelines, and reimbursement policies into precise, testable editing logic.
• Document the source, rationale, and scope of edits so they are traceable, defensible on appeal, and maintainable.
• Distinguish portable, market-wide content from client-specific policy and clearly flag the differences.
• Maintain content through code updates, policy changes, and performance reviews; recommend when edits should be refined or retired.
• Monitor and interpret New York Medicaid sources, including eMedNY provider manuals and fee schedules, NYS DOH Medicaid Update, Medicaid Managed Care contract requirements, and OMIG guidance.
• Translate New York reimbursement rules, including APG and APR-DRG methodologies, into editing logic alongside federal Medicaid NCCI PTP and MUE edits.
• Build content for relevant New York programs and provider types, including Mainstream Managed Care, HARP, behavioral health, FQHC, and long-term care services.
• Track New York policy changes and keep state content current.
• Use claims data to test editing concepts before build, size opportunities, and estimate hit rates, false-positive rates, and savings.
• Review edit output and production results to verify edits fire as intended and identify gaps, over-reach, or missed opportunities.
• Track accuracy, hit rates, false positives, appeals, overturns, provider abrasion, and realized savings.
• Prioritize content based on opportunity, confidence, and expected client value.
• Work with Product, Engineering, and Data Science to turn content concepts into clear requirements, logic specifications, and test cases.
• Provide clinical, coding, Medicaid benefit, eligibility, and billing context to data scientists for models and analyses.
• Evaluate how AI tools, including large language models, can support policy research, concept discovery, content authoring, and quality review.
• Review AI-generated content using expert judgment and help define standards for accuracy.
• Explain editing content rationale, sources, and expected impact 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 New York Medicaid coverage against state policy; and deliver a prioritized list of 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 York policy changes, 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