Senior Content Analyst (Claims editing)

Responsibilities

• Policy Interpretation & Edit Development
• Interpret and apply CMS, Medicare, Medicaid, AMA/CPT, NCCI, and other payer policies to define accurate claims editing logic.
• Translate regulatory and coding guidance into clear, deterministic pre-pay edits, with documented rationale and references.
• Build and maintain a proprietary library of claims edits aligned to reimbursement rules and industry standards.
• Identify reimbursement risk areas and policy interpretation gaps and encode them into actionable edit concepts.
• Claims Validation & Analysis
• Own the development of high-quality edit specifications, including logic definitions, assumptions, edge cases, and validation criteria.
• Analyze claims and edit performance data to confirm accuracy, reduce false positives, and prioritize enhancements by impact.
• Conduct targeted manual claim reviews to validate coding accuracy, reimbursement correctness, and policy alignment.
• Cross-Functional Enablement
• Serve as a SME across Medicare, Medicaid, and commercial claims.
• Partner with product, engineering, and implementation teams to ensure edits are implemented and validated correctly.
• Clearly document edit logic, policy interpretation, and outcomes to support internal teams and payer stakeholders.
• Governance & Ongoing Maintenance
• Proactively monitor regulatory updates, coding changes, and industry guidance to keep edits current and compliant.
• Ensure all edits are auditable, defensible, and aligned with external policy sources.
• Consistently meet productivity and quality expectations in a remote, outcomes-driven environment.
• What You Bring:
• 4+ years of experience in authoring claims editing content with either vendors or payers
• Deep expertise in:
• CMS policies (LCDs, NCDs, fee schedules)
• NCCI (PTP and MUE) edits, OIG guidance, correct coding methodologies
• CPT/HCPCS, ICD-10-CM/PCS, modifiers, place of service, and revenue codes
• Strong understanding of claims processing workflows (CMS-1500, UB-04).
• Extra points if you bring:
• SQL skills for claims analysis or edit opportunity identification.
• Clinical background (RN, BSN, PharmD, MD, or equivalent).

Benefits

Additional Information

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. We're seeking a skilled Senior Content Analyst to join our Claims Editing team! As a Sr. Content Analyst on the Payment Integrity - Policy & Content Management team, you will interpret healthcare reimbursement policies and translate them into precise, automated claims editing logic that drives payment accuracy. 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. 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. 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.

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