Machinify

Medical Director

Remote - US · Director

Sponsorship not specifiedDetected 18 hours ago

Data AnalysisPatient CareLeadershipCommunication

About the role

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.
The Medical Director serves as a clinical subject matter expert and physician leader for an audit organization supporting governmental and commercial payer programs.
The Physician hired for this role will join a team of other Medical Directors, all reporting to the Executive Medical Director at Machinify.

Support audit methodologies, clinical validation frameworks, sampling approaches, and quality assurance processes to ensure consistency, defensibility, and regulatory alignment.
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.
Support client engagements by explaining clinical rationale, audit findings, documentation expectations, and defensible review standards.

Required and Preferred Qualifications
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.

Ability to synthesize complex clinical, coding, and claims information into clear, defensible medical opinions and audit rationales.
Experience collaborating with coding professionals, nurse reviewers, data analysts, compliance leaders, legal teams, and payer stakeholders.
Comfortable working in a structured audit environment with expectations for consistency, accuracy, timeliness, and regulatory defensibility.
Commitment to ethical review practices, clinical integrity, confidentiality, and objective application of evidence-based standards.
Medical degree (MD or DO) required.
Board certification in an ABMS or AOA-recognized specialty preferred.
Experience with governmental payer programs, including Medicare, Medicaid, and/or Medicare Advantage, strongly preferred.
No current sanctions, exclusions, or restrictions from federal or state governmental healthcare programs.

In accordance with applicable state laws, we do not inquire about salary history during the recruitment process.

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.
This role provides medical oversight for audit strategy, clinical review methodologies, coding and documentation interpretation, claims validation, medical necessity determinations, and appeal support.
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.
Apply knowledge of Medicare, Medicaid, Medicare Advantage, managed care, and commercial payer policies to audit findings, provider education, and client deliverables.
Promote clinical accuracy, reviewer consistency, ethical audit practices, and continuous improvement across medical review operations.
Strong understanding of governmental and commercial payer operations, including Medicare, Medicaid, Medicare Advantage, managed care, and employer-sponsored health plan environments.
Demonstrated ability to interpret payer policies, medical necessity criteria, clinical guidelines, coding standards, and documentation requirements.

al 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

This listing is sourced directly from Machinify's careers page and normalized into a canonical job model.