What You’ll Do
Lead pre and post-pay claim reviews to identify inaccurate payments using reimbursement and contract expertise.
Analyze and interpret provider contracts to ensure payments align with negotiated terms, methodologies, and payer rules.
Collaborate closely with engineering and data science teams to translate business and reimbursement logic into analytical and automation frameworks.
Research and document emerging reimbursement and contract patterns, coverage rules, and billing practices to inform concept development.
Translate complex reimbursement and contract scenarios into structured rules and business logic for implementation.
Analyze claim-level data to pinpoint root causes of overpayments or incorrect denials and recommend corrective approaches.
Maintain expertise on CMS and commercial payer reimbursement guidelines.
Support quality review, concept validation, and process improvement initiatives.
What You Bring
5+ years of experience in healthcare data mining or claims editing on the provider, payer, or vendor side.
Deep understanding of provider contracts, including rate structures, carve-outs, and reimbursement methodologies.
Strong knowledge of claims processing, coding, billing, and payment logic across CMS and commercial payers.
Proven ability to identify improper payment patterns, root causes, and opportunities for correction.
Strong investigative and deductive reasoning skills; able to connect policy, data, and contractual details.
Comfortable working in close collaboration with technical teams to guide implementation of business logic.
Self-directed, detail-oriented, and adaptable to a fast-paced, growing environment.
Preferred Qualifications
Coding certification (e.g., CPC, CCS, or equivalent).
Working proficiency in SQL for data exploration and validation.
Prior experience in cross-functional R&D or innovation teams focused on healthcare payment integrity.
What We Offer
Work from anywhere in the US! Machinify is digital-first.
Top Medical/Dental/Vision offerings
FSA/HSA
Tuition reimbursement
Competitive salary, 401(k) with company match
Additional health and wellness benefits and perks
Flexible and trusting environment where you’ll feel empowered to do your best work
The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc.
Pay range: $125,000 - $135,000
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/
