Payment Integrity Manager (Bill Review) (RN)

Alaffia Health•,

About The Position

Alaffia is a healthtech startup focused on reducing improper payments and administrative waste in health plans. As the Manager, Itemized Bill & Medical Review, you will lead a team of Medical Bill Reviewers responsible for high-quality facility bill audits. This role requires a blend of clinical expertise and operational execution, ensuring accuracy, consistency, and scalability in audit work. It's an ideal opportunity for an experienced bill reviewer and clinical auditor to step into leadership, structure a growing team, and drive the quality and throughput of the Payment Integrity program.

Requirements

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.
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.

Nice To Haves

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

Responsibilities

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.
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.
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.
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.
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.