Lead Medical Director - Claim Editing
Machinify · United States
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 size opportunities with data.
- Evaluate where AI tools, including large language models, can improve concept discovery, research, validation, and performance analysis.
- Apply physician judgment to AI-generated content and help establish appropriate clinical oversight and safeguards.
- Represent the clinical perspective in product strategy, prioritization, and roadmap decisions.
Advise clients
- Serve as a trusted clinical advisor to health plan leaders.
- Lead discovery sessions and present the rationale, methodology, evidence, expected impact, and AI-enabled capabilities behind editing concepts.
- Translate complex clinical, coding, reimbursement, and AI topics into clear recommendations.
- Support client policy-adoption and approval processes and bring client feedback into the product roadmap.
- Represent Machinify at client meetings, industry events, and conferences.
What You’ll Bring
Required
- MD or DO from an accredited medical school with an 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, beyond authoring individual rules.
- Ability to translate complex clinical and coding scenarios into actionable editing logic.
- Strong analytical skills and experience using data and performance measures to validate clinical hypotheses and improve outcomes.
- Experience working with Product, Engineering, Data Science, Operations, Coding, or other multidisciplinary teams.
- General understanding of AI tools and workflows, along with the ability or willingness to discuss AI-enabled capabilities with clients.
- Executive presence and excellent communication skills across clinical, technical, client, and nonclinical 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.