Specialty Pharmacy Claims Editor & Content Innovator

OpenKrill; United States; On-site; 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 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