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.About the RoleWe are seeking a physician executive to serve as the clinical leader and executive partner to our health plan clients. Reporting to the CEO, the CMO will drive trusted client relationships, guide payment integrity policy, and represent the clinical voice in product innovation. This role emphasizes executive engagement and strategic influence, supported by a strong internal team managing day-to-day operations.Key ResponsibilitiesExecutive Client Engagement &amp; Strategic Leadership<ul><li>Build trusted partnerships with client Medical Directors, Payment Integrity executives, and senior payer stakeholders.</li></ul><ul><li>Partner with clients to validate results, demonstrate clinical credibility, and drive adoption of payment integrity solutions.</li></ul><ul><li>Collaborate with sales and customer success teams to support business development and long-term partnership growth.</li></ul>Payment Policy &amp; Clinical Guidance<ul><li>Shape payer-specific payment policies for accurate enforcement in the Machinify system.</li></ul><ul><li>Provide evidence-based clinical and coding rationale during client audits, appeals and escalations.</li></ul><ul><li>Advise on complex reimbursement constructs across CMS, Medicaid, and commercial plans, including DRG classifications, OPPS/APC, NCCI, CPT/HCPCS, and modifier logic.</li></ul><ul><li>Maintain alignment with authoritative industry standards (CMS NCCI, AMA CPT, ICD-10 guidelines, AHIMA briefs).</li></ul>Cross-Functional Collaboration<ul><li>Partner closely with operations, engineering, data science, product, and client services teams to ensure outputs are clinically sound.</li></ul><ul><li>Mentor internal clinicians and guide clinical playbooks and escalation protocols.</li></ul>Product &amp; Innovation Leadership<ul><li>Represent the clinical perspective in product roadmap and innovation initiatives.</li></ul><ul><li>Advance clinical content innovation to ensure defensibility, scalability, and impact.</li></ul><ul><li>Shape the platform to move beyond identifying payment errors to diagnosing root causes and enabling systemic improvements.</li></ul>Required Qualifications<ul><li>MD or DO with active license.</li></ul><ul><li>10+ years in payment integrity, reimbursement operations, or claims auditing. Expertise across inpatient, outpatient, and professional claims (DRG, APCs, CPT/HCPCS, modifier logic).</li></ul><ul><li>Strong knowledge of CMS, Medicare, Medicaid, and commercial payer adjudication rules.</li></ul><ul><li>Proven executive-level client engagement experience.</li></ul><ul><li>Demonstrated leadership and ability to translate clinical insights into strategy.</li></ul>Preferred Qualifications<ul><li>Experience with pharmacy claims, PBM workflows, or claims editing platforms (ClaimCheck, CES, Lyric).</li></ul><ul><li>Familiarity with AI/NLP or automation-driven audit workflows.</li></ul><ul><li>Advanced degree (MBA, MPH, MHA).</li></ul>Equal Employment Opportunity at MachinifyMachinify is committed to hiring talented and qualified individuals with diverse backgrounds for all of its positions. Machinify believes that the gathering and celebration of unique backgrounds, qualities, and cultures enriches the workplace. See our Candidate Privacy Notice at: <a target="_blank" href="https://www.machinify.com/candidate-privacy-notice/">https://www.machinify.com/candidate-privacy-notice/</a>

Machinify

Chief Medical Officer

Machinify

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