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

Machinify; United States; À distance; USD 120 000 - 160 000; Plein temps

Résumé du poste

Machinify seeks an experienced Content Innovation, Claims Editing specialist focused on New York Medicaid to source, design, validate, and maintain clinical and coding content for editing products. You will transform policy into precise edits and measure value for health plan clients in a largely remote role.

The ideal candidate has deep editing/coding expertise, a robust analytical mindset, and a proactive stance on using AI to speed content authoring while preserving clinical accuracy.

Qualifications

• 7+ years in claims editing or payer policy with hands-on edit authoring/validation.
• Active coding credential (CPC/CCS/CCS-P/CPMA/CIC) or a clinical license (RN).
• Deep CPT/HCPCS/ICD-10-CM knowledge, NCCI, MUEs, and coding guidelines.
• Experience with reimbursement methodologies including fee schedules, DRGs, APCs.
• Sourcing and interpreting CMS manuals, NCDs/LCDs, AMA guidance, and payer policies.
• Strong analytical skills; comfortable with claims data using SQL/Excel to test hypotheses.

Responsabilités

• Source and author editing content from authoritative sources such as CPT/HCPCS, ICD-10-CM, NCCI, and CMS manuals.
• Translate coding rules and reimbursement policy into precise, testable editing logic.
• Document source, rationale, and scope for every edit; ensure traceability and maintainability.
• Maintain content through quarterly updates and policy changes; flag when edits should be refined.
• Limit client-specific policy to separate portable, market-wide content and clearly flag differences.
• Monitor NY Medicaid sources (eMedNY, NYS DOH updates, OMIG guidance) and NY APGs/APR-DRGs rules.

Connaissances

Analytical skills

SQL

Excel

Communication

AI curiosity

Team collaboration

Formation

CPC / CCS / CCS-P / CPMA / CIC

RN or equivalent clinical license

Outils

SQL

Excel

BI tools

Description du poste

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

Remote - US

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

Machinify is redefining Payment Integrity through smarter technology, richer data, and intelligent automation. We are seeking a claims editing content expert to help build the next generation of editing content and make healthcare payments more accurate and affordable. This role will bring deep expertise in New York State Medicaid.

As Content Innovation, Claims Editing - NY Medicaid you will source, design, validate, and maintain the clinical and coding content that powers our editing products. You will find opportunities in policy and in the data, turn them into edits that hold up, and measure whether they deliver value for our health plan clients. Your focus will be New York State Medicaid, where you will be our go-to expert on state policy and how it shapes editing.

This is a build-and-scale role at the intersection of clinical editing, coding, reimbursement policy, data science, and product development. The ideal candidate brings deep clinical editing and coding expertise, a strong analytical instinct, and an open, practical interest in how AI can help us build better content, faster, while keeping quality and clinical accuracy at the center.

You do not need to be a data scientist. You do need to think in terms of evidence, measurable outcomes, and the value each edit creates for a client.

What you’ll do

Source and author editing content

• Monitor and interpret authoritative 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 reimbursement policies.
• Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic.
• Document the source, rationale, and scope of every edit so it is traceable, defensible on appeal, and easy to maintain.
• Separate portable, market-wide content from client-specific policy, and flag the difference clearly in all content and sizing work.
• Maintain existing content through quarterly code updates, policy changes, and performance reviews, and 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 the programs and provider types that matter most to New York plans, such as Mainstream Managed Care, HARP, behavioral health, FQHC, and long-term care services.
• Track New York policy changes and keep state content current.

Validate content with data

• Use claims data to test editing concepts before build, size the opportunity, and estimate hit rate, false-positive rate, and savings.
• Review edit output and production results to confirm edits fire as intended and to find gaps, over-reach, or missed opportunities.
• Track measures such as accuracy, hit rate, false positives, appeals, overturns, provider abrasion, and realized savings.
• Bring an analytical, value-first view to prioritization: what is the opportunity, how confident are we, and what will it return for the client?

Partner with Product and Data Science

• Work with Product, Engineering, and Data Science to turn content concepts into clear requirements, logic specifications, and test cases.
• Help data scientists understand clinical and coding context so models and analyses reflect how care is delivered and billed. Bring Medicaid benefit, eligibility, and billing context to that work.
• Evaluate where AI tools, including large language models, can speed up policy research, concept discovery, content authoring, and quality review.
• Apply expert judgment to AI-generated content and help define the review standards that keep it accurate.

Support clients and internal teams

• Explain the rationale, sources, and expected impact behind editing content to client and internal audiences.
• Support client policy review, edit approval, and appeals with clear, well-sourced documentation.
• Bring client feedback and operational findings back into the content roadmap.

What experience you bring (Role Requirements)

Required

• 7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with hands-on experience authoring or validating edits.
• 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 the 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.

Preferred

• 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.

What Success Looks Like…

First 90 Days