Medical Director

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🇺🇸 United States – Remote

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

💰 $10M Series A - Machinify on 2018-10

Healthcare Insurance • Artificial Intelligence • SaaS

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Provide clinical leadership and medical oversight for audit programs involving governmental and commercial payer claims. • Review and interpret medical records, claims data, coding patterns, clinical documentation, and payer policies to support accurate audit determinations. • Evaluate medical necessity, level of care, site of service, coding accuracy, documentation sufficiency, and alignment with applicable clinical standards and payer requirements. • Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment. • Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables. • Partner with audit operations, coding, clinical review, data analytics, compliance, legal, and client-facing teams to resolve complex clinical and payment integrity issues. • Provide physician-level review and support for disputes, rebuttals, grievances, appeals, and provider-facing clinical explanations. • Participate in the development and maintenance of clinical audit guidelines, review protocols, policy interpretation tools, and reviewer training materials. • Monitor regulatory updates, payer policy changes, coding guidance, clinical practice trends, and audit risk areas that may affect governmental or commercial payer work. • Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards. • Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations. • Other related job duties, as assigned by executive leadership.

🎯 Requirements

• Medical degree (MD or DO) required. • Active, unrestricted medical license in good standing required; willingness to obtain additional licensure may be preferred based on business needs. • Board certification in an ABMS or AOA-recognized specialty preferred. • Minimum of 5+ years of direct clinical patient care experience post-residency or fellowship required; experience in inpatient, post-acute, emergency medicine, hospital medicine, internal medicine, surgery, or a payer-relevant specialty preferred. • Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, strongly preferred. • Experience with commercial payer policies, managed care operations, utilization management, medical necessity review, claims audit, coding review, appeals, or payment integrity preferred. • No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs. • Prior experience in an audit company, payer organization, payment integrity vendor, utilization management organization, or highly regulated healthcare environment strongly preferred.

🏖️ Benefits

• Equal Employment Opportunity at Machinify