Director, Payment Integrity

Alaffia Health•,

1d•Onsite

About The Position

Alaffia is a healthtech startup focused on reducing improper payments and administrative waste in U.S. health plans. They use expert clinicians and AI to provide claims operations support, aiming to lower healthcare costs. The Director, Payment Integrity will lead the strategy, performance, and scaling of Alaffia's Payment Integrity review programs, including Itemized Bill Review, Medical Record Review, and DRG Validations. This role involves managing a team of Managers and reviewers, setting program direction, translating client needs into operational execution, and acting as the senior clinical and operational authority for Payment Integrity. The ideal candidate has experience managing managers, P&L or KPI accountability, and a desire to build a best-in-class payment integrity function.

Requirements

8+ years of experience in medical bill review, facility coding, clinical auditing, or payment integrity, including 4+ years leading managers or running a multi-team review organization.
Deep expertise across a broad range of Payment Integrity review types, including but not limited to UB-04/facility claim auditing, Itemized Bill Review (IBR), with extensive experience with coding accuracy, confirming billed charges, and comparing claims against supporting medical records across multiple payer types and lines of business (LOBs).
Proven track record owning program-level KPIs (accuracy, throughput, SLA, quality) and driving measurable improvement at scale.
Strong working knowledge of national coding guidelines: CPT, ICD-10-CM/PCS, HCPCS, DRGs, APCs, revenue codes, and POS codes.
Experience serving as a senior point of contact for client executives, including presenting performance data and leading escalations.
Demonstrated ability to build and scale teams — hiring, developing managers, and establishing career pathing and training programs.
Excellent written and verbal communication skills, with experience presenting to executive audiences (internal and client-side).
Knowledge of HIPAA/PHI compliance standards and payer-specific audit policies.
Active RN license or higher-level clinical license strongly preferred; equivalent senior clinical/coding leadership background will be considered.
Current authorization to work in the United States.

Nice To Haves

Prior experience at a health plan, payment integrity vendor, or managed care organization in a director or senior leadership capacity.
Experience owning or heavily influencing AI/ML-assisted review workflows or model validation processes.
Background across multiple audit types — DRG validation, readmissions review, itemized bill review, or coding audits.
Familiarity with revenue cycle operations and hospital billing workflows.
At least one relevant certification (CPC, CIC, CRC, CPMA, or equivalent).
Experience operating in a high-growth startup environment, building process and structure from limited existing scaffolding.

Responsibilities

Own the overall strategy, roadmap, and operating model for the Payment Integrity review program, including Itemized Bill Review (IBR) and facility/DRG audit workstreams.
Lead and develop a team of Managers, providing them the coaching, structure, and resources to run high-performing review teams.
Set org-wide performance standards and targets for audit accuracy, throughput, SLA adherence, and findings quality, and hold managers accountable to them.
Build the multi-quarter capacity plan for the review organization, forecasting headcount, hiring needs, and workload against client growth.
Represent Payment Integrity in company-wide planning, budgeting, and leadership discussions.
Serve as the senior clinical authority for audit quality across the program, setting the standards that Managers and reviewers are held to.
Establish escalation paths for high-complexity, high-dollar, or high-risk audit disputes, and make final calls when needed.
Ensure audit methodology and findings remain defensible and consistent with national coding guidelines (CMS, CPT, ICD-10, HCPCS, DRG, APC, revenue codes) and payer-specific policy across all client programs.
Own the audit quality assurance framework, including calibration across reviewers/managers and periodic program-level quality reviews.
Partner with Product/Engineering on how AI and automation get incorporated into review workflows, ensuring clinical accuracy and defensibility are preserved as the program scales.
Own the end-to-end operating model connecting operations (intake, documentation requests, provider outreach) with clinical review execution, in partnership with Payment Integrity Operations leadership.
Approve and continuously refine SOPs across all audit workflows: intake, review methodology, documentation, escalation, and appeals support.
Identify systemic bottlenecks across the program and drive cross-functional initiatives to improve cycle time, capacity, and reviewer efficiency.
Own SLA performance across the full review queue and ensure contractual commitments are met at scale across multiple client programs.
Serve as a senior point of contact for client executives on Payment Integrity program performance, escalations, and strategic account decisions.
Own client-facing reporting on program performance — accuracy, savings/findings, throughput, and trends — and present at executive business reviews.
Lead client escalations, appeals discussions, and provider dispute resolution for the most complex or highest-stakes cases.
Partner with Sales/Managed Services on scoping new client programs, staffing models, and program design during Implementations & onboarding.
Hire, develop, and retain a strong bench of Managers, building a leadership pipeline within the review organization.
Establish career paths, training curricula, and audit playbooks that support reviewer and manager growth across the org.
Build a culture of clinical rigor, accountability, and continuous improvement across the entire Payment Integrity organization.
Own root-cause analysis and corrective action processes for program-level quality or client escalation trends, reporting findings and remediation plans to leadership.
Own the KPI framework for the Payment Integrity organization: audit accuracy, throughput, SLA compliance, findings per case, appeal overturn rate, and client savings/impact metrics.
Establish and lead the reporting cadence to company leadership on program health, growth, quality trends, and capacity.
Stay ahead of coding guideline updates, CMS policy changes, and payer requirements, ensuring the org adapts proactively.
Contribute Payment Integrity domain expertise to company-level strategic initiatives, including product roadmap input and AI/automation strategy.