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?