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.
About the Opportunity
We’re seeking a skilled IBR Policy and Content Development Analyst to join our team! You will be responsible for the development, enhancement, and performance of clinical and coding solutions. This role serves as the primary subject matter expert for payment integrity policies, leveraging expertise in healthcare payment policies, facility billing, coding, and regulatory requirements. This role works closely with cross-functional teams – including operations, clinical, client services, and IT – to ensure audit concepts are accurately built, validated, and maintained in alignment with coding standards, medical necessity criteria, and client-specific payer policies.
The ideal candidate will possess extensive knowledge in medical coding systems and payment methodologies, as well as have strong analytical and communication skills. The candidate brings a proven track record of leading audit concept development and driving payment integrity initiatives.
What You’ll Do
- Review and update existing audit concepts on required regular cycles or in response to client or regulatory changes, including research, data/claim analysis, and updates to rule documents and code lists.
- Conduct research and analysis to identify the impact of regulatory, coding, or payer policy changes on existing concepts and document findings accordingly.
- Interpret and apply client-specific payer policy in audit concept reviews and updates.
- Research, interpret, and embed state-specific Medicare/Medicaid provider manuals and regional regulatory mandates into audit concept configurations.
- Evaluate payer policies to proactively identify gaps and propose new, audit concepts to clients.
- Ensure audit concepts are appropriately formulated across offering types and program lines (Medicaid, Medicare, Commercial).
- Align concepts with industry standards, including CMS, MUEs, and CPT/HCPCS coding guidelines.
- Develop, validate, and maintain audit concepts targeting coding unbundling in accordance with NCCI edits.
- Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
- Benchmark concept outcomes against industry standards, historical data, and client baselines to identify gaps and optimization areas.
- Participate in testing for new concepts to verify that the automated logic performs accurately in the system environment before implementation.
- Confirm audit concepts are validated against current coding guidelines, payment methodologies, and payer policy prior to deployment.
- Ensure consistent and correct application of policies across platforms and client programs by the audit teams.
- Collaborate with cross-functional teams to develop clinical and coding solutions, audit strategies, and payment integrity initiatives and policies.
- Identify opportunities to improve audit concept workflows and documentation processes.
- Support ongoing enhancements to concept tracking and cross-function coordination.
- Leverage AI tools and automation to optimize policy development, streamline research, and scale payment integrity solution performance.
- Perform additional responsibilities and ad hoc projects as assigned to meet business needs.
What You Bring
- 3+ years’ experience performing payment integrity or auditing facility claims.
- Experience translating complex medical regulations and payer guidelines into clear, legally compliant clinical content and structured policy documentation.
- Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
- Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
- Knowledge of national coding standards, particularly payment rules.
- Strong organizational and written communication skills.
- In-depth knowledge of diverse facility reimbursement methodologies and commercial/government payment policies to ensure accurate contract compliance and audit integrity.
- Proficient in Windows office systems, including the full Microsoft Suits (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
- Demonstrated experience or proficiency in utilizing AI tools and automation platforms to optimize clinical research.
- Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with clients.
- Ability to prioritize and multitask.
Required Skills/Qualifications:
License/Certification
- At least one of the following coding certificates:
- RHIA, RHIT, CCS, CPC, CPMA
- Or, Active RN/LPN License
Pay range: $85,000 - $110,00 USD
This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.
What’s in it for you
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/ 
