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Alaffia Health is a venture-backed Series B healthtech startup on a mission to reduce billions in improper payments and administrative waste across the U.S. healthcare system. Using expert clinicians and transparent AI, the company partners with health plans to deliver deeper insights, smarter automation, and better outcomes across the claims lifecycle.
You will join the Appeals and Disputes team as a Clinical Itemized Bill Reviewer, responsible for investigating and resolving provider disputes related to Payment Integrity audit findings. Your primary focus will be high-dollar facility claims and itemized bills.
Key responsibilities include:
- Reviewing and investigating provider disputes tied to Payment Integrity findings
- Analyzing itemized bills, UB-04 claim forms, medical records, clinical documentation, and coding information
- Determining whether disputed findings should be upheld, modified, or overturned based on evidence
- Comparing itemized bills and claim forms against medical records to validate charges and assess accuracy
- Researching and applying relevant clinical, coding, billing, and payer-specific guidelines
- Developing clear, well-supported written responses to provider disputes
- Identifying inconsistencies between claims billed, clinical documentation, coding, and health plan payments
- Validating coding and billing findings using applicable code sets and reimbursement guidelines
- Managing a high-volume queue of disputes while maintaining accuracy and quality
- Partnering with PIA Managers and Payment Integrity teams on complex cases
- Identifying trends and recurring issues to improve audit processes
- Maintaining PHI/HIPAA compliance
You will work in a flat organizational structure with direct access to leadership, contributing to a mission-driven team passionate about transforming healthcare efficiency.
REQUIREMENTS:
- Active RN (Registered Nurse) license required
- 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or related healthcare claims function
- Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings
- Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s
- Deep knowledge of medical billing, coding, clinical documentation, and insurance claims
- Experience evaluating whether billed services and charges are supported by medical records and clinical documentation
- Strong understanding of relevant coding and reimbursement systems (CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code sets)
- Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines
- Ability to analyze complex clinical and claims information and translate findings into clear, defensible written responses
- Strong attention to detail and ability to manage high-volume case queue while maintaining accuracy and quality
- Strong written and verbal communication skills
- Ability to work collaboratively with Payment Integrity teams and PIA Managers
PREFERRED:
- At least one of the following certifications: CPC, CIC, CRC, CPMA, or equivalent
- Experience working for a health plan, insurance company, or Payment Integrity organization
- Experience with high-dollar facility bill review and complex claim auditing
- Knowledge of PHI/HIPAA compliance and standards
