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

Rawlings Company; United States; Hybrid; USD 135,000 - 165,000; Full time

Benefits offered by this job

Remote and hybrid work options

PTO, Holidays, and Volunteer Days

Tuition Reimbursement

401(k) with company match

Health, vision and dental coverage

Job summary

Machinify seeks a claims editing content expert to help build the next generation of editing content and improve the accuracy of healthcare payments, with a strong focus on New York State Medicaid.

You will source and author content from CPT/HCPCS, ICD-10-CM, NCCI, and CMS materials, translating rules into precise editing logic. You will test concepts using claims data with SQL/Excel and collaborate with Product and Data Science to deliver measurable client value.

Qualifications

• 7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy with hands-on editing experience.
• Active coding credential (CPC/CCS/CCS-P/CPMA) or clinical license (RN) 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 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.
• Experience collaborating 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 NY Medicaid policy knowledge including eMedNY, APGs, APR-DRGs, NYS DOH and OMIG guidance.

Responsibilities

• Source and author editing content by monitoring authoritative sources (CPT/HCPCS, ICD-10-CM, NCCI, MUEs, CMS manuals, NCDs/LCDs).
• Translate coding rules and reimbursement policy into precise editing logic and document rationale for traceability.
• Maintain content with quarterly updates and flag client-specific vs market-wide content.
• Collaborate with Product, Engineering, and Data Science to create specifications and test cases.
• Test edits with claims data to estimate hit rate, false positives, and savings; review outputs for gaps or improvement opportunities.
• Explain rationale and sources to clients and internal teams; support policy reviews and appeals.

Skills

Claims editing

Clinical coding

Payer policy

Analytical skills

Claims data familiarity

Education

CPC/CCS/CCS-P/CPMA or CIC credential or RN license

Tools

SQL

Excel

Job description

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.

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.

Bring depth in New York State Medicaid

• 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

You will learn Machinify's content portfolio, source library, technology, and development process; build working relationships with Product and Data Science; assess current New York Medicaid coverage against state policy; and deliver a prioritized list of New York content gaps and opportunities.

Within 6 to 12 months

You will own a content domain end to end, move multiple data‑validated concepts into production, maintain accurate and current source documentation, contribute to at least one AI‑assisted improvement in how content is built, set up a repeatable process for tracking New York policy changes, and show measurable results in edit accuracy, speed, or client value.

Pay range: $135,000 - $165,000 USD

This exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company‑paid benefits including life insurance, short‑term disability, and parental leave.
• Remote and hybrid work options

What values we'll share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at https://www.machinify.com/candidate-privacy-notice/