Director, Payment Integrity Solutions

Alaffia Health•,

19h•Remote

About The Position

We are seeking an experienced clinical Payment Integrity (PI) leader who is ready to shift toward a highly client facing role. As Director of Claims Solutions, you will serve as a strategic bridge between Alaffia's innovative AI platform, payment integrity managed services, and our health plan clients. You will lead both pilots and implementations, address complex PI workflow challenges, deliver compelling clinical PI demonstrations, and provide ongoing support to client services and internal operations teams. This is a pivotal role supporting our rapid growth in clinical claims solutions. You will bring deep operator experience from a health plan, PI vendor, or related environment and thrive at translating technical/clinical capabilities into client value.

Requirements

Clinical + PI Operations Experience: 8+ years in healthcare payment integrity, with significant hands-on clinical review or leadership experience (e.g., as a clinical PI operator, Payment Integrity Manager/Director, or equivalent at a health plan or PI vendor). Deep understanding of clinical claim review processes, medical necessity, coding validation (DRG, CPT, etc.), and identifying improper payments.
Client-Facing Orientation: Proven ability (or strong desire) to move from behind-the-scenes operations into client engagement. Experience presenting to executives, leading demos, or consulting on workflow optimization is highly valued.
Implementation Leadership: Track record of successfully leading complex claims or PI solution implementations, including requirements gathering, configuration, testing, and go-live support.
Clinical and Technical Acumen: Strong clinical background (RN, clinical reviewer, or equivalent) paired with familiarity with AI-enabled tools, claims platforms, or automation in payment integrity. Ability to speak credibly about both clinical reasoning and technology.
Communication and Collaboration: Excellent verbal and written communication skills. Ability to translate complex clinical/PI concepts for diverse audiences (clients, internal ops, product teams). Experience liaising between operations and external stakeholders.
Results-Oriented: Demonstrated success in driving savings, improving accuracy, or scaling PI programs.

Nice To Haves

Experience with AI/agentic AI tools in healthcare claims or prior work with platforms focused on transparent clinical AI.
Background in health plan operations, utilization management, appeals, or special investigations unit (SIU).
Knowledge of regulatory environments (e.g., CMS guidelines, state/federal compliance) and common PI challenges like upcoding, unbundling, or coordination of benefits.
Bachelor's or advanced degree in nursing, healthcare administration, or related field. Relevant certifications (e.g., CCS, RHIA, CPC) are a plus.

Responsibilities

Lead Client Implementations and Onboarding: Oversee end-to-end implementations of Alaffia's claims and payment integrity solutions for new and existing clients. This includes scoping requirements, configuring workflows, coordinating with internal teams (e.g., operations, product, engineering, and clinical teams), and ensuring successful go-live with measurable impact on improper payment detection and recovery.
Client-Facing Expertise and Workflow Consulting: Act as a trusted advisor to clients by diagnosing their workflow challenges (pre-pay, post-pay, clinical editing, overpayment recovery, etc.). Provide expert guidance on leveraging Alaffia's AI-driven tools for clinical validation, DRG reviews, upcoding detection, and other complex claim scenarios.
Lead Clinical PI Demonstrations and Sales Support: Deliver high-impact demos and presentations showcasing Alaffia's agentic AI capabilities, clinical reasoning engine, and best-in-class results. Tailor discussions to client pain points in clinical services and payment integrity.
Liaise with Internal Stakeholders: Serve as the primary point of contact between clients and internal teams on claims/PI-related issues. Escalate and resolve operational challenges, ensure alignment on clinical accuracy, and drive continuous improvements to our solutions based on real-world client feedback.
Support Client Services: Provide hands-on support to the client services team as needed, including leading implementations, troubleshooting issues, and contributing to ongoing account management for clinical engagements.
Drive Growth and Best Practices: Collaborate with solutions, product, and sales teams to refine our clinical offerings. Identify opportunities to expand usage of agentic pilots and AI tools within client environments. Stay current on industry trends in healthcare payment integrity, clinical editing, fraud/waste/abuse (FWA) detection, and regulatory changes.
Team Leadership and Collaboration: Mentor junior team members, foster cross-functional collaboration, and contribute to a culture of clinical excellence and client success.