Senior Content Analyst (Claims editing)

<div class="content-intro"><p><span style="color: rgb(0, 0, 0);">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.</span></p></div><div><span style="color: rgb(0, 0, 0);">We’re seeking a skilled Senior Content Analyst to join our Claims Editing team!</span></div> <div> <p><span style="color: rgb(0, 0, 0);">As a Sr. Content Analyst on the Payment Integrity – Policy &amp; Content Management team, you will interpret healthcare reimbursement policies and translate them into precise, automated claims editing logic that drives payment accuracy.&nbsp;This is a deep subject-matter-expert role focused on applying regulatory guidance, coding standards, and payer rules to create deterministic, testable edits that identify incorrect coding, billing, and reimbursement.&nbsp;You’ll own edit concepts end-to-end, from interpretation through validation and ongoing refinement, with opportunities to contribute to the evolution of content approaches over time.&nbsp;This role offers high autonomy and ownership for someone who understands how claims should be paid and thrives on turning complex rules into clear, enforceable logic.</span></p> </div> <div>&nbsp;</div> <div><span style="color: rgb(0, 0, 0);"><strong>What You’ll Do:</strong></span></div> <div> <p><span style="color: rgb(0, 0, 0);">Policy Interpretation &amp; Edit Development</span></p> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Interpret and apply CMS, Medicare, Medicaid, AMA/CPT, NCCI, and other payer policies to define accurate claims editing logic.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Translate regulatory and coding guidance into clear, deterministic pre-pay edits, with documented rationale and references.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Build and maintain a proprietary library of claims edits aligned to reimbursement rules and industry standards.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Identify reimbursement risk areas and policy interpretation gaps and encode them into actionable edit concepts.</span></li> </ul> <p><span style="color: rgb(0, 0, 0);">Claims Validation &amp; Analysis</span></p> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Own the development of high-quality edit specifications, including logic definitions, assumptions, edge cases, and validation criteria.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Analyze claims and edit performance data to confirm accuracy, reduce false positives, and prioritize enhancements by impact.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Conduct targeted manual claim reviews to validate coding accuracy, reimbursement correctness, and policy alignment.</span></li> </ul> <p><span style="color: rgb(0, 0, 0);">Cross-Functional Enablement</span></p> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Serve as a SME across Medicare, Medicaid, and commercial claims.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Partner with product, engineering, and implementation teams to ensure edits are implemented and validated correctly.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Clearly document edit logic, policy interpretation, and outcomes to support internal teams and payer stakeholders.</span></li> </ul> <p><span style="color: rgb(0, 0, 0);">Governance &amp; Ongoing Maintenance</span></p> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Proactively monitor regulatory updates, coding changes, and industry guidance to keep edits current and compliant.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Ensure all edits are auditable, defensible, and aligned with external policy sources.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Consistently meet productivity and quality expectations in a remote, outcomes-driven environment.</span></li> </ul> </div> <div><span style="color: rgb(0, 0, 0);"><strong>What You Bring:</strong></span></div> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">4+ years of experience in authoring claims editing content with either vendors or payers</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Deep expertise in:</span></li> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">CMS policies (LCDs, NCDs, fee schedules)</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">NCCI (PTP and MUE) edits, OIG guidance, correct coding methodologies</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">CPT/HCPCS, ICD-10-CM/PCS, modifiers, place of service, and revenue codes</span></li> </ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Strong understanding of claims processing workflows (CMS-1500, UB-04).</span></li> </ul> <p><span style="color: rgb(0, 0, 0);">Extra points if you bring:</span></p> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">SQL skills for claims analysis or edit opportunity identification.</span></li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Clinical background (RN, BSN, PharmD, MD, or equivalent).</span></li> </ul> <div><span style="color: rgb(0, 0, 0);"><strong>What We Offer:</strong></span></div> <ul> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Work from anywhere in the US! Machinify is digital-first.</span></li> <li style="color: rgb(0, 0, 0);"> <div><span style="color: rgb(0, 0, 0);">Top Medical/Dental/Vision offerings</span></div> </li> <li style="color: rgb(0, 0, 0);"> <div><span style="color: rgb(0, 0, 0);">FSA/HSA</span></div> </li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Solid PTO program</span></li> <li style="color: rgb(0, 0, 0);"> <div><span style="color: rgb(0, 0, 0);">Tuition reimbursement</span></div> </li> <li style="color: rgb(0, 0, 0);"> <div><span style="color: rgb(0, 0, 0);">Competitive salary, 401(k) with company match</span></div> </li> <li style="color: rgb(0, 0, 0);"> <div><span style="color: rgb(0, 0, 0);">Additional health and wellness benefits and perks</span></div> </li> <li style="color: rgb(0, 0, 0);"><span style="color: rgb(0, 0, 0);">Flexible and trusting environment where you’ll feel empowered to do your best work</span></li> </ul> <div><span style="color: rgb(0, 0, 0);">The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc. &nbsp;We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range.&nbsp;</span></div> <div>&nbsp;</div> <div>&nbsp;</div><div class="content-conclusion"><div><span style="color: rgb(0, 0, 0);"><strong>Equal Employment Opportunity at Machinify</strong></span></div> <div>&nbsp;</div> <div><span style="color: rgb(0, 0, 0);">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:&nbsp;<u><a id="m_4907613542122963413OWAae7934b9-fa06-3f98-e336-0c5f8a6d5638" style="color: rgb(0, 0, 0);" href="https://www.machinify.com/candidate-privacy-notice/" target="_blank" data-saferedirecturl="https://www.google.com/url?q=https://www.machinify.com/candidate-privacy-notice/&amp;source=gmail&amp;ust=1763168899816000&amp;usg=AOvVaw0FJrzi47RtxTK_RN63lbaj">https://www.machinify.com/candidate-privacy-notice/</a></u></span></div></div>