Lead Medical Director - Claim Editing

The role

You will lead clinical development and governance of editing content. You will identify opportunities, validate clinical concepts, and ensure edits are evidence-based and scalable using AI-powered platforms.

What you will 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, and defensible on appeal
• Define and monitor measures such as edit accuracy, hit rate, and realized savings
• Partner with Product, Engineering, Coding, Operations, and Data Science to build, test, and scale clinical content
• Apply physician judgment to AI-generated content and establish clinical oversight
• Serve as a trusted clinical advisor to health plan leaders
• Represent Machinify at client meetings, industry events, and conferences

Required qualifications

• MD or DO from an accredited medical school
• Active, unrestricted U.S. medical license
• Significant clinical practice experience and an understanding of real-world provider workflows
• Deep, current knowledge of CPT, HCPCS, ICD-10-CM, NCCI, coding guidelines, documentation requirements, and reimbursement methodologies
• Experience in claims editing, Payment Integrity, coding, utilization management, payer operations, claims operations, or a related field
• Experience building or operating a repeatable clinical content or editing process at scale
• Ability to translate complex clinical and coding scenarios into actionable editing logic
• Strong analytical skills and experience using data and performance measures
• Experience working with Product, Engineering, Data Science, Operations, Coding, or other multidisciplinary teams
• General understanding of AI tools and workflows
• Executive presence and excellent communication skills

Nice to have

• 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

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients through an AI-powered platform.