Alaffia Health
Director, Payment Integrity
US +1 · Director · Full-time · Posted Jul 8, 2026
- Location
- US
Remote (United States) - Experience
- 8+ years in Payment Integrity, clinical auditing, or facility claims review, including 4+ years managing managers or team leads.
- Visa sponsorship
- Requires current authorization to work in the United States; the company does not sponsor work visas.
About the job
Leads the strategy, clinical quality, operations, and growth of Alaffia’s prepay and postpay Payment Integrity review programs, including facility audits and client delivery.
What you'll do
- Set program strategy, operating standards, capacity plans, and KPIs; lead and develop managers.
- Govern audit quality and methodology, resolve complex disputes, and ensure coding and payer-policy alignment.
- Own workflows, client and provider escalations, performance reporting, and cross-functional improvements, including AI-enabled review workflows.
What they ask for
- Active RN license or higher-level clinical license.
- Experience at a Payment Integrity vendor.
- 8+ years in Payment Integrity, clinical auditing, or facility claims review, including 4+ years managing managers or team leads.
- Hands-on experience across DRG/Clinical Validation and IBR/HBA; broad facility PI experience, both prepay and postpay, program scaling, QA/KPI ownership, and client- and provider-facing work.
Nice to have
- Clinical and coding dual credential (e.g., RN with CIC, CCS, CPC, CPMA, CRC, or equivalent); personally performed clinical and coding validation.
- Experience with AI-enabled review or automation, launching PI services, new-client implementations, or scaling vendor/startup operations.
Tools
CMS, CPT, ICD-10-CM/PCS, HCPCS, DRG, APC, revenue codes
AI focus
Partner with Product/Engineering on incorporating AI and automation into review workflows while preserving clinical accuracy and defensibility; contribute to company AI/automation strategy.
Model-written summary · the original posting is authoritative