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 85 health plans, including many of the top 20, and representing more than 270 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.
The Senior Contract Analyst is responsible for ensuring the outpatient and specialty audit teams operate from correct, current payer-provider contracts and payer reimbursement policies. This role identifies and documents contract terms with audit opportunity, including carve-out payments, and maintains the concept matrix that defines which outpatient concepts are applied to each client.
This is a senior individual contributor role requiring independent judgment, good judgment and decisive action in complex or evolving situations, and sound escalation practices. The role requires exceptional organization, the ability to manage a high volume of detail with accuracy, and adaptability to shifting priorities in a fast-paced environment. Clear communication is essential, including the ability to translate complex contract and policy language for auditors, client-facing teams, and leadership.
Key Responsibilities
Contract Accuracy and Governance
- Serve as the single source of truth for payer-provider contracts and reimbursement policies supporting outpatient and specialty audit programs.
- Validate that audit teams have the correct contract version, amendments, fee schedules, and effective dates before audits are performed.
- Build and maintain a contract inventory with version control, renewal tracking, and a clear audit trail of changes.
- Identify missing, expired, or outdated contracts and drive resolution before audit work is affected.
Audit Opportunity Documentation
- Review contracts to identify and abstract terms with audit opportunity, including carve-out payments, implant and device provisions, high-cost drug terms, stop-loss and outlier thresholds, lesser-of language, bundling and packaging rules, and exclusions.
- Translate contract language into clear, usable documentation that auditors can apply consistently.
- Flag ambiguous or conflicting contract language and escalate with a recommended interpretation.
- Partner with audit leadership and policy teams to surface new concept opportunities found in contract terms.
Payer Reimbursement Policy Management
- Maintain the library of payer reimbursement policies supporting outpatient and specialty audit concepts, ensuring the required policies are in place to implement each concept for each client.
- Monitor payer policy updates, retirements, and effective date changes, and update the policy library and impacted concepts as needed.
- Identify policy gaps before a concept is implemented for a client and drive resolution with Client Success and the client.
- Maintain linkage between each concept, its supporting policy, and the client to ensure audit findings are supported by current, defensible policy.
- Communicate policy changes to audit teams to prevent findings based on outdated or superseded policy.
Outpatient Concept Matrix
- Own and maintain the concept matrix mapping which outpatient and specialty audit concepts are active, paused, or excluded for each client.
- Ensure the matrix reflects client-specific contract terms, supporting reimbursement policies, exclusions, and approvals.
- Establish update cadence, change control, and quality checks to maintain matrix accuracy for Ops, Client Success, and leadership.
- Provide reporting and insight on concept coverage gaps and expansion opportunities by client.
Cross-Functional Partnership
- Serve as the primary contract intelligence partner to Client Success teams, providing clear, specific requests to obtain updated contracts, reimbursement policies, and related information from each client.
- Track outstanding client requests through resolution.
- Communicate contract, policy, and concept changes to audit teams to prevent work from being performed on outdated terms.
- Identify process improvements and support scaling of the contract intake and abstraction workflow as the client base grows.
Qualifications
Required
- Bachelor's degree or equivalent professional experience.
- 5+ years of experience in healthcare payment integrity, provider contracting, managed care, claims auditing, or revenue cycle.
- Demonstrated ability to read, interpret, and abstract payer-provider contract terms and reimbursement methodologies.
- Strong working knowledge of outpatient reimbursement, including OPPS/APC, fee schedules, percent of charges, and carve-out structures.
- Working knowledge of payer reimbursement policies and the ability to connect policy language to audit concepts.
- Familiarity with AI tools such as Claude to support contract, policy, and payer research.
- Advanced Excel skills and experience building and maintaining complex tracking tools or matrices.
Preferred
- Coding or clinical credential (CPC, CCS, RHIA, RHIT, or RN).
- Experience with specialty audit areas such as implants, high-cost drugs, or infusion services.
- Experience in a payer, payment integrity vendor, or health system contracting department.
- Familiarity with contract management platforms and data visualization tools.