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

OpenKrill; United States; Remote; USD 140,000 - 190,000; Full time

Job summary

Machinify is seeking a Content Innovation, Claims Editing - Specialty Pharmacy to lead sourcing and authoring of editing content for specialty drugs. You will translate policy and coding rules into precise edits, source authoritative references, and ensure traceable documentation supporting payors and health plans.

The ideal candidate has 7+ years in claims editing or payer policy, carries a coding credential (CPC/CCS/CCS-P/CPMA) or applicable clinical license, and can collaborate with Product

Qualifications

• 7+ years 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 with coding experience.
• Deep knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, guidelines, and documentation requirements.
• Experience with reimbursement methodologies (fee schedules, DRGs, APCs, professional and facility billing).
• Experience sourcing and interpreting CMS manuals, NCDs/LCDs, AMA guidance, and payer policies.
• Strong analytical skills; comfortable using SQL/Excel to test hypotheses and measure results.
• Experience collaborating with Product, Engineering, Data Science or other teams.
• Clear written communication; ability to explain coding/clinical logic to nonclinical audiences.
• Curiosity about AI tools and applying them to content work.
• 3+ years in medical benefit drug billing, HCPCS J-codes, NDCs, units, modifiers, and ASP reimbursement.

Responsibilities

• Source and author editing content from CPT/HCPCS updates, guidelines, payer policies.
• Translate rules and guidelines into precise, testable edits.
• Document sources, rationale, and scope for traceability.
• Separate market-wide from client-specific content and flag differences.
• Maintain content through quarterly updates and policy changes; advise on refining or retiring edits.
• Monitor HCPCS, NDCs, dosing units, and drug modifiers for high-cost drugs.
• Test edits with claims data to estimate hit rate, savings, and errors.
• Collaborate with Product and Data Science to convert concepts into specs and test cases.
• Evaluate AI tools for speed and quality while maintaining accuracy.
• Explain rationale and sources to clients and internal teams; incorporate feedback into roadmaps.

Skills

Claims editing

Clinical coding

Data analysis

SQL

Excel

Communication

AI tooling

Team collaboration

Education

Coding credentials

Pharmacy background

Clinical license

Tools

N/A

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 specialty pharmacy and high-cost drugs.

As Content Innovation, Claims Editing - Specialty Pharmacy 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 specialty and physician-administered drugs billed under the medical benefit, where you will be our go-to expert on drug coding and payment.

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.

Bring depth in specialty pharmacy and high-cost drugs

• Monitor and interpret drug content sources, including FDA prescribing information, drug compendia, NCCN and other clinical guidelines, CMS ASP pricing files, NCDs and LCDs, and payer drug policies.

• Build and maintain edits for HCPCS billing units, NDC-to-HCPCS crosswalks, weight- and BSA-based dosing, maximum units, dose rounding, and drug wastage modifiers such as JW and JZ.

• Cover oncology, immunology, rare disease, biosimilars, and other high-cost therapeutic areas, including new drug launches and new HCPCS codes.

• Track label changes, new approvals, quarterly HCPCS updates, and pricing changes, and keep drug 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 drug dosing, units, 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 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.

Preferred

• 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.

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 drug editing coverage against high-cost therapeutic areas; and deliver a prioritized list of specialty drug 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 approvals, label changes, and HCPCS updates, and show measurable results in edit accuracy, speed, or client value.

Pay range: $1