Payment Integrity Manager (Bill Review) (RN)

About Alaffia & Our Mission Every year, U.S. health plans lose billions to improper payments and administrative waste. That wasted spending ultimately trickles down across the healthcare ecosystem, driving up costs for plans, providers, and patients alike. We’re here to change that paradigm. Alaffia is a new kind of claims operations partner for health plans. Using expert clinicians and transparent AI, we deliver deeper insights, smarter automation, and consistently better outcomes across the entire lifecycle of claims. With Alaffia, health plans can cut wasted spending more effectively than ever — and provide their members the most affordable care. We’re a high-growth, venture-backed Series B healthtech startup based in NYC and are actively scaling our company. Join us in helping to build a healthcare system that works better for everyone. About the Role As the Manager, Itemized Bill & Medical Review, you'll lead and oversee a team of Medical Bill Reviewers (Payment Integrity Analysts) responsible for delivering high-quality, high-dollar facility bill audits on behalf of our health plan clients. You'll sit at the intersection of clinical expertise and operational execution, ensuring your team's audit work is accurate, consistent, and scalable while serving as a key counterpart to the Payment Integrity Operations Manager in delivering a seamless end-to-end audit experience. This role is ideal for an experienced bill reviewer and clinical auditor who is ready to step into a leadership position, bring structure to a growing team, and drive the quality and throughput of our Payment Integrity program.

What You'll Be Doing Team Leadership & Performance Management

• Directly manage a team of Medical Bill Reviewers: assign caseloads, set daily and weekly priorities, conduct 1:1s, and coach reviewers on audit accuracy, documentation standards, and productivity

• Monitor individual and team KPIs including audit throughput, accuracy rates, SLA adherence, and finding quality

• Ensure accountability for timely completion of audit assignments and maintain high standards for documentation and clinical rationale

• Onboard and train new reviewers on internal workflows, audit tools, coding guidelines, and payer-specific policies

• Foster a culture of continuous improvement, clinical accuracy, and professional development within the review team

Audit Quality & Clinical Oversight

• Serve as the clinical authority for audit quality—reviewing escalated cases, resolving coding disputes, and ensuring findings are defensible and well-documented

• Conduct regular quality audits of reviewer work product, identifying trends, knowledge gaps, and opportunities for coaching or process improvement

• Establish and maintain clinical review standards ensuring consistency across all reviewers and client programs

• Validate that audit determinations align with national guidelines (CPT, ICD-10, HCPCS, DRG, APC, revenue codes) and payer-specific policies

• Review and approve high-complexity or high-dollar audit findings prior to client delivery

Program & Workflow Management

• Partner with the PI Ops Manager to ensure seamless handoff between operational workflows (documentation requests, intake, provider outreach) and clinical review execution

• Design and document Standard Operating Procedures (SOPs) for all audit workflows including: case intake, review methodology, finding documentation, escalation paths, and appeals support

• Own and refine internal workflows for caseload management, backlog tracking, and audit throughput optimization

• Identify bottlenecks in the review process and implement solutions to improve cycle time and reviewer efficiency

• Manage the IBR review queue to ensure cases are assigned, reviewed, and completed within contractual SLA timelines

Client & Cross-Functional Collaboration

• Collaborate with the PI Ops Manager and Managed Services team on client onboarding, audit program configuration, and delivery cadence

• Contribute to client-facing reporting by providing clinical context and accuracy validation for audit summaries and findings reports

• Serve as a clinical subject matter expert in client escalations, appeals discussions, and provider dispute resolution

Operational Governance & Continuous Improvement

• Define and track key claim review operational KPIs: audit accuracy rate, throughput per reviewer, findings per case, SLA compliance, appeal overturn rate

• Establish reporting cadence for team performance metrics and deliver regular updates to leadership on audit volume, quality trends, and capacity

• Lead root-cause analysis when audit errors or client escalations occur, implementing corrective actions and process updates

• Stay current on coding guideline updates, CMS policy changes, and payer-specific billing requirements; cascade relevant updates to the review team

• Contribute to the development of training materials, audit playbooks, and reviewer guides to support team growth and consistency

Who You Are Required Qualifications

• Must hold an active RN license or higher-level clinical license. LPNs are not eligible.

• 5+ years of hands-on experience in medical bill review, facility coding, or clinical auditing with at least 2+ years in a leadership, senior, or supervisory role

• Deep expertise in Itemized Bill Review (IBR) and UB-04/facility claim auditing including revenue code validation, charge confirmation, and medical record comparison

• At least one of the following certifications preferred: CPC, CIC, CRC, CPMA, or equivalent coding/audit certification

• Strong working knowledge of national coding guidelines: CPT, ICD-10-CM/PCS, HCPCS, DRGs, APCs, revenue codes, and POS codes

• Proven ability to lead and develop a team of clinical reviewers, manage caseloads, and drive performance

• Excellent written communication skills with the ability to document clinical rationale clearly and professionally

• Strong organizational skills with the ability to manage multiple priorities, reviewers, and client programs concurrently

• Knowledge of HIPAA/PHI compliance standards and payer-specific audit policies

• Proficient in Excel, Google Sheets, and audit management or workflow platforms

Preferred Qualifications

• Experience working at a health plan, payment integrity vendor, or managed care organization

• Familiarity with payer audit programs, pre-pay or post-pay review models, and appeals processes

• Background supporting or collaborating with AI/ML model training or validation workflows

• Experience working with or alongside DRG validation, readmissions review, or other clinical audit types

• Familiarity with revenue cycle operations and hospital billing workflows

• Project management experience (Agile, Lean, or similar) preferred

Core Competencies

• Clinical authority: You are the go-to expert on IBR audit methodology and coding accuracy for your team and your clients

• People leader: You invest in your team's development, hold them accountable with empathy, and build a culture of quality and ownership

• Operational thinker: You see inefficiencies and fix them—building processes, SOPs, and systems that scale

• Detail-oriented: You don't let errors slide; you catch them, understand root causes, and prevent recurrence

• Collaborative partner: You work effectively across clinical, operations, product, and engineering teams to deliver shared outcomes

• Adaptable: You thrive in a fast-paced startup environment where priorities shift and building from scratch is the norm

*This position requires current authorization to work in the United States. Unfortunately, we are not in a position to sponsor work visas at this time. Our Culture Alaffia was born out of our founders’ personal connection to the inefficiency of the U.S. healthcare system. We are deeply mission-driven, with an abiding belief that technology can help create a better future for everyone — and we’re looking for others who share our passion for change to join the team.

What Else Do You Get?

• Competitive compensation package

• Medical, Dental and Vision benefits

• Flexible, paid vacation policy

• Work in a flat organizational structure — direct access to Leadership