Healthcare Services Concept Specialist

ABOUT MACHINIFY:

In October 2025, Machinify acquired Performant and we are now part of the Machinify organization.  Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify’s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We’re reshaping healthcare payment through seamless intelligence. 

ABOUT THE OPPORTUNITY:

Hiring Range: $90,000 - $105,000

The Healthcare Services Concept Specialist provides support to assigned Segment Specialists by maintaining current audit concepts as well as provide support for the development process of new audit concepts. This opening will be focused on creating audit concepts within the MolDX space. Ideal candidates will have at least 10 years of experience in molecular diagnostics and a strong background in claims auditing.

Key Responsibilities:

• Responsible for the review and update of existing concepts based upon required periodic review cycle or as needed based upon client or regulatory changes (research, analysis, update rule documents, code lists and edits accordingly).  Collaborates with and leverages Segment Specialist expertise to ensure on-point results.

• Ensure training material updates (may develop or coordinate) as necessary for changes to existing concepts. -May contribute to development of training materials and tools for new concepts.

• Conduct research, identify impact on existing concepts, and document accordingly (may support Segment specialists with research for new concepts).

• Interpret and apply policy in existing concept review/updates or ask may be requested in support of Segment Specialists for new concepts.

• Support activities required to “package” concepts, including, but not limited to, pulling together necessary documents, and supporting data in appropriate order and locations, coordinating activities and documenting process steps, proofing documents, and tracking/reporting status.

• Ensure audit concepts are well formulated for Offerings (Data Mining vs Complex Audit vs FWA Leads & CMS vs Medicaid vs Commercial)

• Manage, progress, and track multiple tasks within multiple workflows for audit concept maintenance with high degree of accuracy and quality providing status reports and deliver results on-time.

• May contribute to responses to provider/client representative from written inquiries as it pertains to audited Medicare claims, as necessary.

• Stay abreast of industry policy.

• Works very closely with other team members to ensure on time project deliveries, cross train, and knowledge transfer, and maintain required quality and productivity standards.

• Performs other duties as assigned and required to meet business needs.

Knowledge, Skills & Abilities Needed:

• Demonstrated knowledge of applicable Medicare and Commercial policy and claims process, and ability to research and analyze the same, to successfully perform the job.

• Relevant knowledge and experience with ICD-10-CM/PCS, CPT-4, and HCPCS coding.

• Knowledge of the national coding standards, particularly payment rules.

• Knowledge of Medicare and commercial claims processing systems.

• Ability to understand and apply complex policies, procedures, regulations, and legal statutes.

• Strong verbal communication and interpersonal skills; ability to communicate with all levels within the organization and with diverse teams.

• Excellent written communication skills; including proofing and editing.

• Good critical thinking, analytical, questioning, and listening skills; excellent attention to detail.

• Flexibility to handle non-standard situations as they arise; and adaptable to changing business needs in a fast-paced dynamic environment.

• Time management skills for managing multiple tasks simultaneously, while completing work within allocated time frames.

• Strong proficiency in Microsoft Word, Excel, SharePoint (advanced skills highly desirable), and easily learns and adapts to new applications and systems.

Required & Preferred Qualifications:

• At least 2-4 years of audit or Payment Integrity experience.

• CPC, COC, RHIA, or RHIT certification and/or RN.

WHAT WE OFFER:

Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.

Physical Requirements & Additional Notices:

If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required.  Proof of such may be required prior to an offer being made.  It is the Employee’s responsibility to maintain this Internet access at their home office location.

The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.

• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.

• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).

• Regularly sit/stand 8 or more hours per day.

• Occasionally lift/carry/push/pull up to 10lbs.

Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:

• Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions).   Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.

• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.

• Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

• Other requirements may apply.

All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times.  Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify’s Human Resources team to discuss further.

Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.

THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING