Medical Director – DRG Audit, AI Innovation

October 18

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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

• Conduct DRG reviews to validate principal and secondary diagnoses, procedures, and associated coding. • Apply industry standard guidelines, coding rules, and organizational policies to each case. • Deliver clear, well-documented rationale for each determination, suitable for appeal-ready communication. • Translate case-based reasoning and medical judgment into structured feedback for the AI adjudicator. • Flag nuanced “maybe” cases, conflicting data, or gray zones to inform how the AI handles uncertainty. • Collaborate with policy and engineering teams to refine policy JSONs, decision trees, and narrative outputs. • Identify opportunities to capture clinical nuance (progression of illness, comorbid interactions) that improve AI accuracy. • Serve as a subject matter expert for coding teams, nurses, and data scientists. • Provide input on audit guidelines, clinical validation criteria, and education materials. • Participate in quality improvement initiatives to enhance reviewer consistency and platform performance.

🎯 Requirements

• MD/DO with active, unrestricted license. • Board certification in Internal Medicine, Surgery, Family Medicine, or related specialty with inpatient care experience. • 3+ years of experience performing DRG audits, utilization management, or clinical validation reviews. • Deep familiarity with ICD-10-CM/PCS, AHA Coding Clinic guidance, and CMS DRG policies. • Preferred: Experience working with AI-powered or technology-enabled audit platforms. • Demonstrated ability to translate clinical reasoning into structured or algorithmic formats. • Strong written communication skills for audit documentation and collaborative product feedback. • Comfort working in cross-functional teams (clinical, coding, engineering, product)

🏖️ Benefits

• Full Medical/Dental/Vision for employees & their families w/ 100% premium coverage options! • Flexible and trusting environment where you’ll feel empowered to do your best work • Unlimited PTO • Competitive compensation package, 401(k) sponsorship