Lead Medical Director - Claim Editing

The posting, as Machinify wrote it

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

[…]
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/