Integrity Manager; Bill Review); RN

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.

As the Manager, Itemized Bill & Medical Review, you’ll lead and oversee a team of Medical Bill Reviewers (Payment Integrity Analysts) responsible for delivering high-quality, high-dollar facility bill audits on behalf of our health plan clients. You’ll sit at the intersection of clinical expertise and operational execution, ensuring your team’s audit work is accurate, consistent, and scalable while serving as a key counterpart to the Payment Integrity Operations Manager in delivering a seamless end-to-end audit experience.

This role is ideal for an experienced bill reviewer and clinical auditor who is ready to step into a leadership position, bring structure to a growing team, and drive the quality and throughput of our Payment Integrity program.

• 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 I  review queue to ensure cases are assigned, reviewed, and completed within contractual SLA timelines