Physician Reviewer (AI Solutions)

Alaffia Health•New York, NY

14d•Remote

About The Position

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. This role can be based either in our NYC headquarters or remotely. We’re looking for someone who ….

Requirements

Clinical Credentials: MD with active or recent clinical experience; expertise in DRG validation, medical necessity reviews, or similar areas preferred.
Health Plan Expertise: Familiarity with payer systems, health plan workflows, payment integrity, and coding methodologies (e.g., MS DRG, APR DRG). Previous experience as a Physician Review a plus.
Payment Integrity Knowledge: Keen understanding of clinical payment integrity reviews such as DRG validation, readmission, short stay, and hospital bill audit,
Generative AI Enthusiast: A passion for GenAI and a curiosity about how large language models can be applied to solve healthcare challenges.
Tech Savvy: Comfortable working with AI-powered tools and technology; experience collaborating with technical teams.
Client-Facing Skills: Excellent communication skills with the ability to explain clinical concepts and AI capabilities to both clinical and non-clinical audiences.
Analytical Mindset: Strong attention to detail with the ability to validate and interpret clinical data and medical records.
Innovative Spirit: Enthusiasm for working at the intersection of healthcare and AI to solve complex problems and improve industry outcomes.
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.

Responsibilities

Team Leadership: Lead a team of professionals responsible for annotating and validating medical data, testing AI models, and ensuring clinical accuracy in product outputs.
Cross-Functional Collaboration: Partner with our AI Engineering, Product, and Claims teams to train and refine generative AI models, incorporating clinical insights to ensure features meet client needs.
Product Development: Provide clinical input to product teams to design features that align with industry standards and address healthcare payer pain points.
AI Model Training: Help design and oversee processes for annotating datasets to train large language models, ensuring clinical knowledge is effectively embedded in AI tools.
Quality Assurance: Validate evidence in medical records, focusing on areas like DRG assignments, medical necessity determinations, and evidence-based decision-making to ensure the accuracy and reliability of large language models.
Client Engagement: Serve as a clinical subject matter expert (SME) in client demos, sales discussions, and onboarding. Communicate the value of Alaffia’s generative AI solutions to clinical and non-clinical stakeholders.
Education and Evangelism: Advocate for the use of generative AI in healthcare by educating internal teams, external clients, and partners about its transformative potential.