Healthcare Services Concept Specialist (Certified Outpatient Coding SME)

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: $78,500 - $104,000

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.

 

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 Qualification