Content Innovation, Claims Editing – Specialty Pharmacy (Multiple Levels)

The role

You will source, design, validate, and maintain clinical and coding content for editing products. The role focuses on specialty and physician-administered drugs billed under the medical benefit.

What you will do

• Source and author editing content
• Monitor and interpret authoritative sources like CPT, HCPCS, and ICD-10-CM
• Translate coding rules and clinical guidelines into testable editing logic
• Document the source, rationale, and scope of every edit
• Maintain existing content through quarterly updates and policy changes
• Build and maintain edits for HCPCS billing units and NDC-to-HCPCS crosswalks
• Track label changes, new approvals, and pricing changes
• Use claims data to test editing concepts and estimate savings
• Partner with Product, Engineering, and Data Science teams
• Support client policy review, edit approval, and appeals

Required qualifications

• 7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy
• Active coding credential, such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license paired with deep coding experience
• Deep, current knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation requirements
• Working knowledge of reimbursement methodologies, including fee schedules, DRGs, APCs, and professional and facility billing
• Experience sourcing and interpreting primary content, including CMS manuals, NCDs and LCDs, AMA guidance, and payer policies
• Strong analytical skills and comfort working with claims data, using SQL, Excel, or similar tools
• Experience working with Product, Engineering, Data Science, or other multidisciplinary teams
• Clear written communication
• Curiosity about AI tools and willingness to use them in daily content work
• At least 3 years of hands-on experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement
• Sound judgment and comfort working in a fast-moving build-and-scale environment

Nice to have

• Pharmacy background, such as PharmD, RPh, or CPhT, or experience in specialty pharmacy, infusion, or oncology practice billing
• Experience with 340B billing rules, biosimilar adoption, or oncology drug policy
• Experience at a claims editing, Payment Integrity, or healthcare technology company
• Experience across commercial, Medicare Advantage, and Medicaid lines of business
• Clinical background (RN, LPN, or other licensed clinician) with direct patient care experience
• Experience writing product requirements or logic specifications for engineering teams
• Experience with Python, SQL, or BI tools for claims analysis
• Experience presenting content rationale or savings analyses to health plan clients

Benefits

• PTO
• Paid Holidays
• Volunteer Days
• Eligibility for health, vision and dental coverage
• 401(k) plan participation with company match
• Flexible spending accounts
• Tuition Reimbursement
• Company-paid life insurance
• Company-paid short-term disability
• Company-paid parental leave

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. It uses an AI-powered platform to maximize financial outcomes and drive down healthcare costs.