Director, Payment Integrity

About Alaffia & Our MissionEvery 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. About the RoleAs the Director, Payment Integrity, you'll own the strategy, performance, and scale of Alaffia's Payment Integrity review programs — including DRG Validation, Clinical Validation, Itemized Bill Review (IBR), Hospital Bill Audit (HBA), medical record review, readmissions, short stay, complex outpatient, and related facility PI review functions across both prepay and postpay. You'll lead a team of Managers (and, through them, a broader bench of Medical Bill Reviewers/Payment Integrity Analysts), setting the direction for how the program grows, translating client and executive priorities into operational execution, and serving as the senior clinical and operational authority for Payment Integrity across the company.This role is ideal for a seasoned Payment Integrity or clinical audit leader who has already managed managers, owns program-level P&L or KPI accountability, and wants to help build a payment integrity function from a scaling stage into a mature, best-in-class operation. What You'll Be DoingProgram Strategy & LeadershipOwn the overall strategy, roadmap, and operating model for the Payment Integrity review program, including DRG Validation, Clinical Validation, IBR/HBA, readmissions, short stay, complex outpatient, and IRF/SNF/BH facility audit workstreams, across prepay and postpayLead and develop a team of Managers, providing them the coaching, structure, and resources to run high-performing review teamsSet org-wide performance standards and targets for audit accuracy, throughput, SLA adherence, and findings quality, and hold managers accountable to themBuild the multi-quarter capacity plan for the review organization, forecasting headcount, hiring needs, and workload against client growthRepresent Payment Integrity in company-wide planning, budgeting, and leadership discussionsClinical & Audit Quality GovernanceServe as the senior clinical authority for audit quality across the program, setting the standards that Managers and reviewers are held toEstablish escalation paths for high-complexity, high-dollar, or high-risk audit disputes, and make final calls when neededEnsure 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 programsOwn the audit quality assurance framework, including calibration across reviewers/managers and periodic program-level quality reviewsPartner with Product/Engineering on how AI and automation get incorporated into review workflows, ensuring clinical accuracy and defensibility are preserved as the program scalesProgram & Workflow OwnershipOwn the end-to-end operating model connecting operations (intake, documentation requests, provider outreach) with clinical review execution, in partnership with Payment Integrity Operations leadershipApprove and continuously refine SOPs across all audit workflows: intake, review methodology, documentation, escalation, and appeals supportIdentify systemic bottlenecks across the program and drive cross-functional initiatives to improve cycle time, capacity, and reviewer efficiencyOwn SLA performance across the full review queue and ensure contractual commitments are met at scale across multiple client programsClient & Executive Relationship ManagementServe as a senior point of contact for client executives on Payment Integrity program performance, escalations, and strategic account decisionsOwn client-facing reporting on program performance — accuracy, savings/findings, throughput, and trends — and present at executive business reviewsLead client escalations, appeals discussions, and provider dispute resolution for the most complex or highest-stakes casesPartner with Sales/Managed Services on scoping new client programs, staffing models, and program design during Implementations & onboardingTeam Building & Organizational DevelopmentHire, develop, and retain a strong bench of Managers, building a leadership pipeline within the review organizationEstablish career paths, training curricula, and audit playbooks that support reviewer and manager growth across the orgBuild a culture of clinical rigor, accountability, and continuous improvement across the entire Payment Integrity organizationOwn root-cause analysis and corrective action processes for program-level quality or client escalation trends, reporting findings and remediation plans to leadershipOperational Governance & ReportingOwn the KPI framework for the Payment Integrity organization: audit accuracy, throughput, SLA compliance, findings per case, appeal overturn rate, and client savings/impact metricsEstablish and lead the reporting cadence to company leadership on program health, growth, quality trends, and capacityStay ahead of coding guideline updates, CMS policy changes, and payer requirements, ensuring the org adapts proactivelyContribute Payment Integrity domain expertise to company-level strategic initiatives, including product roadmap input and AI/automation strategy Who You AreRequired QualificationsActive RN license or higher-level clinical license — requiredExperience working at a Payment Integrity vendor (not health plan or MCO alone) — understanding the pace, client expectations, program implementation, audit delivery, provider abrasion, and performance accountability of a vendor environment8+ years in Payment Integrity, clinical auditing, or facility claims review, including 4+ years managing managers / team leads (not just directly supervising auditors)Deep hands-on operational experience across both DRG Validation / Clinical Validation AND Itemized Bill Review (IBR) / Hospital Bill Audit (HBA) — including inpatient facility claims, medical record review, ICD-10-CM/PCS, revenue codes, charge validation, and audit methodologyBroad facility PI breadth — DRG + IBR plus meaningful ownership of other audit types such as medical record / clinical review, readmissions, short stay, complex outpatient, IRF/SNF, or behavioral healthExperience leading both prepay and postpay PI programs — not postpay aloneHas built or scaled a PI program, service line, workflow, or operating model from the ground up (or materially scaled/matured an existing one)Owns program-level QA and KPIs — audit accuracy, throughput, SLA compliance, findings per case, appeal overturn rate, savings/impactClient AND provider facing — has presented audit results, program performance, trends, and escalations to client executives AND defended findings directly with providers in high-stakes conversationsStrong operational leadership — staffing/capacity planning, SOPs, training, workflow design, escalations, performance management, continuous improvementStrong working knowledge of national coding guidelines: CPT, ICD-10-CM/PCS, HCPCS, DRGs, APCs, revenue codesExcellent written and verbal communication skills with executive audiencesKnowledge of HIPAA/PHI compliance standards and payer-specific audit policies Preferred QualificationsClinical + coding dual credential — RN with CIC, CCS, CPC, CPMA, CRC, or equivalent coding certificationHas personally performed both clinical validation and coding validationHas launched a new PI product or audit service line end-to-end — methodology → staffing → QA → implementation → client reportingExperience with AI-enabled review, automation, rules engines, or technology-supported clinical auditingExperience supporting POCs, implementations, sales support, solutioning, and new-client program designExperience in a high-growth startup or rapidly scaling vendor environment — comfortable building process and structure from limited existing scaffoldingFamiliarity with revenue cycle operations and hospital billing workflowsCore CompetenciesProgram owner: You think in terms of the whole program — capacity, quality, client outcomes, and P&L — not just a single teamPeople developer: You build leaders, not just manage individual contributors; you invest in Managers the way they invest in reviewersExecutive communicator: You're comfortable owning the room in a client business review or a leadership planning sessionClinical authority: Active clinician who sets the bar for audit methodology, clinical validation, and coding accuracy across the entire organizationSystems thinker: You design for scale — processes, tooling, and organizational structure that hold up as volume growsAdaptable builder: You thrive in a fast-paced startup environment where you're building the plane while flying itThis position requires current authorization to work in the United States. Unfortunately, we are not in a position to sponsor work visas at this time. Our CultureAlaffia was born out of our founders' personal connection to the inefficiency of the U.S. healthcare system. We are deeply mission-driven, with an abiding belief that technology can help create a better future for everyone — and we're looking for others who share our passion for change to join the team. What Else Do You Get?Competitive compensation packageMedical, Dental and Vision benefitsFlexible, paid vacation policyWork in a flat organizational structure — direct access to Leadership