Director – New Product R&D

November 3

🏄 California – Remote

Although this job is listed in California, this company may be open to hiring remote in other states.

⏰ Full Time

🔴 Lead

👔 Director

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Machinify, Inc.

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Artificial Intelligence • Healthcare Insurance • Fintech

Machinify, Inc. is a company specializing in artificial intelligence solutions for the healthcare industry, particularly in optimizing payment processes and enhancing payment integrity. Their product suite, including Machinify Audit and Machinify Pay, is designed to automate and improve the accuracy of medical claims review, identifying billing and coding errors, and reducing administrative costs. Machinify's AI-driven platform covers millions of healthcare members and delivers significant financial benefits by efficiently processing medical claims and empowering health plans to tailor their policies. With a focus on transparency, control, and safety in AI, Machinify offers customized solutions that adapt to the specific needs of healthcare providers and contribute to the transformation of healthcare payments.

51 - 200 employees

🤖 Artificial Intelligence

⚕️ Healthcare Insurance

💳 Fintech

💰 $10M Series A on 2018-10

📋 Description

• Lead domain strategy within Product • Define the domain vision and standards for Payment Integrity across prepay and postpay use cases, aligning clinical, coding, and policy rigor with Machinify’s product strategy and business goals. • Help establish governance for policy/clinical accuracy, model and rule validation, and compliance-by-design; set the quality bar and go/no-go criteria for releases. • Platform-first discovery and solutioning • Develop deep expertise in Machinify’s platform capabilities (data ingestion/normalization, rules/decisioning, model training/evaluation, reviewer workbench, explainability/audit, X12/EDI integrations). • Use platform capabilities to drive concept ideation and solution design, recommending configure-vs-build paths to accelerate delivery and scalability. • Partner hands-on with Data Science • Define ground-truth labeling guidance, sampling strategies, and evaluation metrics (precision/recall, dollar yield, false positive rate, overturn rate, provider abrasion). • Review and critique features and model outputs; identify failure patterns and recommend model, rule, or policy adjustments. • Maintain curated test sets and UAT plans that reflect NCCI edits (PTP/MUE), DRG/APC logic, CMS NCD/LCD, plan-specific rules, and fraud/waste/abuse patterns. • Be the market and regulatory intelligence engine • Monitor and synthesize CMS updates (IPPS/OPPS), NCD/LCD, NCCI, state regulations, payer policy trends, provider billing behaviors, and the vendor/competitive landscape. • Deliver concise POVs and impact briefs; translate shifts into product opportunities, risks, and design constraints to inform PM-led prioritization and long-term bets. • Bridge SME Operations insights into product decisions • Aggregate and structure inputs from SME Operations, client services, and customers into prioritized problem statements and actionable requirements that improve model accuracy, reviewer efficiency, and auditability. • Support cross-functional execution and enablement • Participate in requirement reviews, design critiques, and readiness checks; oversee UAT to ensure features meet acceptance criteria and compliance needs. • Conduct trainings and workshops that upskill Product, Engineering, and Data Science on domain concepts and platform implications; create clear domain documentation. • Measure outcomes and iterate • Define domain-level OKRs and success metrics with PM and DS (e.g., yield, accuracy, time-to-detect, overturns, provider abrasion) and drive continuous improvement through analytics and qualitative feedback. • Provide executive-level communication, influence, and stakeholder management across Product leadership and with strategic customers and partners.

🎯 Requirements

• 10+ years in healthcare with 7+ years focused on Payment Integrity, claims analytics, medical coding/audit, or payer operations at a health plan, PI vendor, or consultancy. • 4–6+ years leading cross-functional domain initiatives or teams; experience hiring, mentoring, and setting standards for SMEs/analysts. • 3+ years partnering directly with Data Science and Engineering on data-driven products; health tech experience required. • Strong, hands-on experience with a Payment Integrity platform (e.g., Machinify or comparable) and demonstrated ability to drive configure-vs-build decisions. • Deep understanding of claims data and adjudication flows, including X12/EDI (837P/I/D, 835), CARC/RARC, billing guidelines, and payer policy. • Strong grasp of coding and regulatory standards: ICD-10-CM/PCS, CPT/HCPCS, DRG/APC, NCCI (PTP/MUE), CMS NCD/LCD, IPPS/OPPS, and relevant state regulations; familiarity with FWA concepts a plus. • Knowledge of compliance, privacy, and auditability requirements (HIPAA/PHI handling, explainability, traceability). • Expert at validating user stories, acceptance criteria, decision tables, and comprehensive test plans; proficient with Jira. • Data fluency: able to interpret analytics dashboards, partner on experiments, and evaluate model/rule performance with DS. • Executive presence with excellent facilitation and written communication; able to translate complex policy into clear product decisions for technical and non-technical audiences. • Proven track record influencing PM-led prioritization and aligning Engineering and DS around domain-driven requirements. • Bachelor’s degree in health administration, informatics, nursing/clinical discipline, public health, or related field required; advanced degree preferred. • Relevant credentials such as CPC, CCS, RHIA/RHIT, RN, or similar are preferred.

🏖️ Benefits

• Equal Employment Opportunity at Machinify