Lead Medical Director - Claim Editing

Machinify; Northern (KY); Hybrid; USD 240,000 - 420,000; Full time

Job summary

Machinify, a healthcare intelligence leader, seeks a Lead Medical Director - Claims Editing to steer clinical editing content and governance. You will drive AI-enabled improvements, validate concepts, and ensure edits are evidence-based, scalable, and defensible.

Your role spans clinical medicine, coding, data science, and product collaboration across the payer space. The position requires an MD/DO with a valid U.S.

Qualifications

• MD or DO with active U.S. medical license.
• Significant clinical practice experience and understanding of real-world provider workflows.
• Deep knowledge of CPT, HCPCS, ICD-10-CM, NCCI, coding guidelines, documentation requirements, and reimbursement methodologies.
• Experience in claims editing, Payment Integrity, coding, utilization management, payer operations, or related field.
• Experience building or operating a repeatable clinical content or editing process at scale.
• Ability to translate complex clinical and coding scenarios into actionable editing logic.
• Strong analytical skills with data-driven validation of hypotheses.
• Experience collaborating with Product, Engineering, Data Science, Operations, and Coding teams.

Responsibilities

• Lead clinical editing strategy and governance across editing content.
• Translate clinical, coding, reimbursement, and regulatory developments into editing concepts.
• Establish scalable governance standards for clinical review, coding validation, and documentation.
• Ensure edits are clinically sound and defensible on appeal.
• Review high-impact content before implementation and refine or retire edits as needed.
• Define and monitor measures like edit accuracy, hit rate, and savings.
• Partner with Operations and client teams to address performance gaps.
• Collaborate with Product, Engineering, and Data Science to build AI-enabled content and roadmap.

Skills

MD/DO

Medical license

CPT/HCPCS knowledge

ICD-10-CM knowledge

Claims editing

Data-driven

Interdisciplinary collaboration

AI concepts

Education

MD or DO from an accredited medical school

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.

The Opportunity

Machinify is redefining Payment Integrity through smarter technology, richer data, and intelligent automation. We are seeking a physician leader to help build the next generation of claims editing and make healthcare payments more accurate and affordable.

As Lead Medical Director - Claims Editing, you will lead clinical development and governance of editing content. You will identify opportunities, validate clinical concepts, evaluate performance, and ensure edits are evidence-based, defensible, measurable, and scalable.

This is a build-and-scale role at the intersection of clinical medicine, coding, Payment Integrity, data science, product development, and AI. The ideal candidate brings deep clinical and coding expertise, claims-editing or Payment Integrity experience, and a mindset focused on:

“What is possible with AI?” rather than “What are we comfortable with?”

You do not need to be an AI engineer. You do need to be curious about how AI can strengthen clinical reasoning, content development, and client outcomes.

What You’ll Do

Lead clinical editing strategy and governance

• Identify opportunities where clinical knowledge, coding rules, claims data, and AI can improve Payment Integrity.
• Translate clinical, coding, reimbursement, and regulatory developments into actionable editing concepts.
• Establish scalable standards for clinical review, coding validation, documentation, governance, and continuous improvement.
• Ensure edits are clinically sound, appropriately targeted, aligned with provider workflows, and defensible on appeal.
• Review complex or high-impact content before implementation and recommend when existing edits should be refined or retired.

Connect content to measurable outcomes

• Define and monitor measures such as development cycle time, edit accuracy, hit rate, false-positive rate, appeals, overturns, provider abrasion, and realized savings.
• Use claims data and production results to validate opportunities, evaluate performance, and guide content priorities.
• Partner with Operations and client teams to identify and address gaps between expected and actual performance.

Shape AI-enabled products

• Partner with Product, Engineering, Coding, Operations, and Data Science to build, test, and scale clinical content.
• Translate clinical concepts into actionable product requirements and help size opportunities with data.
• Evaluate where AI tools, including large language models, can improve concept discovery, research, validation, and performance analysis.
• Apply physician judgment to AI-generated content and help establish appropriate clinical oversight and safeguards.
• Represent the clinical perspective in product strategy, prioritization, and roadmap decisions.
• Serve as a trusted clinical advisor to health plan leaders.
• Lead discovery sessions and present the rationale, methodology, evidence, expected impact, and AI-enabled capabilities behind editing concepts.
• Translate complex clinical, coding, reimbursement, and AI topics into clear recommendations.
• Support client policy‑adoption and approval processes and bring client feedback into the product roadmap.
• Represent Machinify at client meetings, industry events, and conferences.

What You’ll Bring

Required

• MD or DO from an accredited medical school with an active, unrestricted U.S. medical license.
• Significant clinical practice experience and an understanding of real-world provider workflows.
• Deep, current knowledge of CPT, HCPCS, ICD-10-CM, NCCI, coding guidelines, documentation requirements, and reimbursement methodologies.
• Experience in claims editing, Payment Integrity, coding, utilization management, payer operations, claims operations, or a related field.
• Experience building or operating a repeatable clinical content or editing process at scale, beyond authoring individual rules.
• Ability to translate complex clinical and coding scenarios into actionable editing logic.
• Strong analytical skills and experience using data and performance measures to validate clinical hypotheses and improve outcomes.
• Experience working with Product, Engineering, Data Science, Operations, Coding, or other multidisciplinary teams.
• General understanding of AI tools and workflows, along with the ability or willingness to discuss AI-enabled capabilities with clients.
• Executive presence and excellent communication skills across clinical, technical, client, and nonclinical audiences.
• Curiosity, sound judgment, and comfort working in a fast-moving build-and-scale environment.

Preferred

• Direct claims‑editing or Payment Integrity experience, particularly with a healthcare technology, editing, or Payment Integrity organization.
• Experience developing, validating, implementing, or optimizing clinical edits.
• Experience across commercial and government lines of business.
• Formal coding certification, such as CPC or CCS.
• Experience launching a new product, content portfolio, or clinical program.
• Experience presenting clinical, Payment Integrity, or AI‑related solutions to health plan clients.

What Success Looks Like

In the first 90 days, you will learn Machinify’s content portfolio, technology, clients, and development processes; build key cross-functional relationships; strengthen clinical review standards; and identify priority content and AI opportunities.

Within 6 to 12 months, you will move validated concepts into production through a repeatable governance process, establish program metrics and performance reviews, implement at least one AI‑assisted improvement, and demonstrate measurable gains in content quality, speed, consistency, or scalability.

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/

Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.

As set forth in Machinify’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.