Director, Specialty Solutions

Who We Are

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 60 health plans, including many of the top 20, and representing more than 160 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.

Location: This role is full remote

About the Opportunity

At Machinify, we’re constantly reimagining what’s possible in our industry—creating disruptively simple, powerfully clear ways to maximize our clients’ financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions team, you will, as Director, Speciality Solutions, review leads a team responsible for reviewing claims across Ambulatory Payment Classification (APC), Behavioral Health, Emergency Department (ED) Leveling, and other specialty outpatient claim types. This leader ensures review accuracy, compliance with client requirements and policies, regulatory compliance, and operational excellence, with a strong focus on quality assurance (QA) and team performance. The Director collaborates with each team’s respective managers to maximize process efficiency and drive scalable growth.

What you’ll do

Strategic Leadership

• Oversee all outpatient claim review operations, including APC, Behavioral Health, ED leveling, and specialty claims.
• Develop and implement review protocols, standards, and workflows in alignment with regulatory and client requirements.
• Set performance targets and quality benchmarks for review teams, ensuring high productivity and accuracy.
• Partner with client success and sales teams to maintain communication with clients and support a collaborative relationship and smooth implementations.
• Oversee the team structure for capacity planning, budgeting, and to ensure alignment with client expectations and SLAs.
• Responsible for driving the value of the Outpatient Specialty review programs, including partnership with content developers to ensure programs are actively meeting the needs of our clients and reflect the dynamic payment integrity landscape.

Team Management

• Mentor review staff and managers to foster a culture of accountability and continuous improvement.
• Manage production team managers, monitor workloads, and optimize resource allocation to meet review volume and turnaround goals.
• Actively monitor and clearly communicate trends relating to client volumes, savings and revenue, team performance, and client onboarding initiatives.
• Conduct regular performance evaluations and provide coaching for skill development.

Quality Assurance & Accuracy

• Oversee QA programs for the Specialty Outpatient Reviews to ensure reviews are accurate, consistent, and compliant with internal and client standards.
• Analyze error trends, support corrective action initiatives, and lead root cause analysis for recurring issues.
• Ensure the maintenance of detailed review records, prepare trending reports, and monitor results to support continuous improvement.