Integrity Concept Development Analyst

US

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.

Required credential:
Active RN license or Certified Coder (CPC/CCS/CIC/COC).

As part of the Complex Payment Solutions Team, the
Concept Development Analyst applies subject matter expertise across government and commercial healthcare claim types to lead the development, maintenance, testing, and optimization of payment integrity audit concepts. This role works closely with cross-functional teams — including operations, clinical, client services, and technology — to ensure audit concepts are accurately built, validated, and maintained in alignment with coding standards, medical necessity criteria, regulatory requirements, and client-specific payer policies.

This role requires deep expertise in medical coding systems and payment methodologies, strong analytical and communication skills, and a proven ability to manage complex workflows independently. The ideal candidate brings authoritative knowledge of healthcare billing across claim types, a track record of leading audit concept development, and the ability to mentor and oversee a team of subject matter experts.

What You’ll Do:

Policy Development and Maintenance

• Review and update existing audit concepts on required periodic 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.
• Ensure audit concepts are appropriately formulated across offering types (Data Mining vs. Complex Audit) and program lines (CMS, Medicaid, Commercial).

Policy Testing and Validation

• Perform QA reviews of audit concepts, ensuring compliance with regulatory, coding, and citation changes, and that updates are applied timely.
• Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
• Ensure audit concepts are validated against current coding guidelines, payment methodologies, and payer policy prior to deployment.

Operational and Workflow Support

• Manage, track, and progress multiple tasks across concurrent audit concept workflows with a high degree of accuracy and quality, delivering results on time.
• Ensure consistent and correct application of policies across auditing platforms and client programs by the audit teams.

Training and Documentation

• Contribute to the creation of training materials, job aids, and reference tools for both new and existing audit concepts.
• Maintain organized, accessible documentation of audit policies and concept updates.

Cross-Functional Collaboration and Client Support

• Respond to client inquiries and provide subject matter support to client services for presentations and escalations.
• Partner with operations, clinical teams, technology, and internal stakeholders to support policy execution and drive concept quality.
• Provide expert feedback to improve policy usability, accuracy, and effectiveness across the organization.

Performance Monitoring…