Billing Accuracy Policy Lead

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

As part of the Complex Payment Solutions Team, the Billing Accuracy Policy Lead is responsible for understanding how coding and clinical audits are performed today; documenting audit logic and decision criteria; and translating those insights into clear, actionable business requirements that will drive the development of AI-guided decision-making tools. This role plays a key part in guiding policy creation, ensuring alignment with clinical and coding standards, ensuring alignment with regulatory requirements, and ensuring deliverables are aligned with client guidelines and policies. The Billing Accuracy Policy Lead serves as a critical bridge between the audit teams and the AI product organization among other internal and external stakeholders; and they ensure clear documentation, testing, training, and implementation of policy-related tools and content.

This role demands a blend of analytical expertise, strong clinical and coding experience, operational coordination, technical acumen, and excellent written and verbal communication skills. The ideal candidate will have demonstrated success in AI guided-related policy work, particularly with stakeholder coordination and collaborative multi-disciplinary teamwork.

What you'll do

• Audit Process Analysis and Documentation
  
  
  
  • Partner closely with audit teams to observe, analyze, and document endtoend audit workflows across multiple claim types (facility, professional, pharmacy, specialty programs, etc.).
  • Capture detailed audit criteria, including clinical and coding validation standards, billing requirements, and payerspecific policies.
  • Identify the data elements, documentation sources, and decision points auditors use to validate or invalidate billed services.
  • Develop standardized audit logic documentation that can be consistently applied across programs.
  • Document and maintain clear and accessible policy materials.
  
  
  
  

• Business Requirements Development
  
  
  
  • Translate audit rules, decision pathways, and validation criteria into structured business requirements for AIdriven decision support tools.
  • Define user stories, acceptance criteria, and logic flows that accurately reflect realworld audit decisionmaking.
  • Collaborate with product managers, data scientists, and AI-engineers to ensure requirements are technically feasible and aligned with business and product strategy.
  • Participate in planning and iterative refinement of requirements as models evolve.
  
  
  
  

• Cross-Functional Collaboration
  
  
  
  • Serve as the subject matter expert for payment integrity audit logic during AI model development.
  • Work with audit teams to ensure logic aligns with regulatory and contractual requirements.
  • Coordinate and document the outcome of testing of policy output to ensure accuracy and effectiveness.
  • Provide feedback on model outputs, identify gaps, and help refine AI decision pathways to improve accuracy and audit readiness.
  • Support change management efforts by helping operational teams understand new AI enabled workflows.
  • Partner with audit training team to ensure effective training and upskilling of audit teams and new hires on the use of job aids and claim review tools.
  
  
  
  

• Quality Assurance & Continuous Improvement
  
  
  
  • Validate that AI generated recommendations align with documented audit criteria and industry standards.
  • Identify opportunities to streamline audit processes and enhance consistency through automation.
  • Monitor performance metrics and partner with analytics teams to evaluate the impact of AI guided decision support.
  • Contribute to continuous improvement of policy management workflows
  
  
  
  

• Other Duties
  
  
  
  • Perform additional responsibilities and ad hoc projects as assigned
  
  
  
  

What experience you bring (Role Requirements)

• Bachelor's degree (health administration, business, nursing, and/or related degree)
• Equivalent experience of 5+ years in healthcare billing and coding
• Equivalent experience of 3+ years in claims auditing and recovery auditing
• Experience developing clinical content, policy documentation, or training resources
• Proven experience working within a team, sharing audit process knowledge with technical and product development teams
• Proven knowledge of coding classifications such as ICD-10, CPT, and HCPCS as well as inpatient and outpatient and outpatient payment systems such as MS-DRG, APR-DRG, APCs, OPPS and EAPGs
• Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
• Strong experience in data utilization and insights
• Experience independently structuring and executing complex analyses
• Demonstrated ability to work efficiently and effectively cross-functionally and independently
• High standards of quality and attention to detail
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
• Ability to create and maintain policies based off of coding guidelines, CPT Assistant, AHA Coding Clinic, and/or other industry standard .
• Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures
• Expert knowledge of clinical criteria documentation requirements
• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficient in Windows office systems, including the full Microsoft Suite and Teams
• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various software applications and collaboration with development teams
• Familiarity with multiple encoder/grouper applications

What Success Looks Like...

After 3 months

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• You've gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

• You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• You've been entrusted with greater responsibility indicating the company's confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $120,000 - $130,000 USD

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

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

What values we'll share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results