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.

Regulatory & Compliance Oversight

• Remain current with changes in APC, CMS, and payer guidelines; ensure review processes reflect the latest requirements.
• Ensure compliance with HIPAA, Medicare, Medicaid, and commercial payer policies.
• Serve as a resource to team managers and leads for all lines of business including Medicare, Medicaid, and Commercial as well as audit types including pre-pay and post-pay.

Process Improvement

• Identify and implement process enhancements to improve review efficiency, accuracy, and team performance.
• Develop improved processes for scalability, including suggestions for system improvements, automation opportunities, and overall streamlined work efforts.
• Leverage technology and data analytics to optimize review workflows and reporting.

Required Qualifications

• Bachelors degree in Health Information Management, Business, Nursing, or related field (Masters preferred)
• Minimum 7 years of healthcare claims reviewing experience, with at least 3 years in a production management role
• Expertise in APC, outpatient coding (CPT, HCPCS, ICD-10), and hospital billing
• Exceptional attention to detail with strong written and verbal communication skills.
• Capable of handling multiple projects in a fast paced, hyper-growth environment
• Proficiency with review and billing software, data analysis, and Microsoft Office
• Advanced knowledge of payer review requirements and regulatory standards

Preferred Skills

• Professional certification: RHIA, RHIT, CCS, CPC, or equivalent preferred

What Success Looks Like...

After 3 months

You will have a strong understanding of the role.

You begin building relationships and collaborating with peers.

You develop effective time and priorities management.

You receive initial feedback about your performance and are using it to improve.

You've gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.

You have established a strong network of internal relationships and are recognized as a key collaborator.

You've been entrusted with greater responsibility indicating the company's confidence in your abilities.

You see opportunities for career progression and personal development.

Pay range: $130,000-$160,000 USD

This is an exempt position. The salary range is for Base Salary.Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

What values we'll share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results

At Machinify, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative, accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer.

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