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Job detailsApplication formAbout 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.*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.About the RoleAlaffia is seeking an experienced Clinical DRG Auditor to join our Payment Integrity team. In this role, you will perform inpatient Diagnosis-Related Group (DRG) validation audits and detailed clinical reviews of medical records and claims. You will leverage your clinical expertise and deep understanding of reimbursement, documentation standards, and coding guidelines to identify unsupported DRGs, improve payment accuracy, and inform audit automation.This role is ideal for an RN or LPN with hands-on experience in clinical DRG validation, inpatient auditing, or CDI-adjacent review work.What You'll be DoingClinical DRG Review & ValidationPerform comprehensive clinical DRG audits on inpatient claims, including validation of principal diagnosis, secondary diagnoses, CCs/MCCs, procedures, sequencing, and discharge status.Evaluate whether clinical documentation supports the billed DRG in accordance with CMS guidelines, payer policies, and nationally accepted standards of care.Apply clinical judgment and clinical guidelines to interpret complex inpatient medical records, including physician notes, labs, imaging, procedures, and treatment plans.Identify documentation gaps, unsupported diagnoses, and DRG upcoding or misclassification.Audit Documentation & ReportingProduce clear, defensible audit findings with concise clinical rationale.Accurately document audit determinations in Alaffia’s audit platform and supporting tools.Support quality assurance processes and peer review as needed.Compliance & Policy AdherenceMaintain working knowledge of ICD-10-CM/PCS coding principles, DRG groupers (MS-DRG, APR-DRG, AP-DRG as applicable), CMS guidance, and payer-specific reimbursement policies.Ensure all audit activity complies with HIPAA, regulatory requirements, and internal SOPs.Cross-Functional CollaborationCollaborate with payment integrity operations, product, and engineering teams to provide clinical insight that informs audit logic and AI-driven review models.Contribute to ongoing process improvements, training, and audit optimization initiatives.Who You AreRequired QualificationsActive Registered Nurse (RN) license3+ years of experience performing clinical DRG validation, inpatient clinical review, DRG auditing, CDI review, or similar payment integrity work.Strong ability to interpret inpatient medical records and assess clinical validity of diagnoses and procedures.Experience applying clinical judgment in a reimbursement or audit context.Preferred QualificationsDirect experience conducting DRG audits for payers, vendors, or consulting organizations.Working knowledge of inpatient reimbursement methodologies and hospital billing workflows.Familiarity with payer audit programs, pre-pay or post-pay reviews, and appeals support.Experience working with audit platforms, EHRs, and claims data systems.Certifications (Preferred, Not Required)CPC, CCS, CIC, CPMA, CCDS, CDIP, or similar clinical/coding/audit certification.Core CompetenciesStrong analytical and critical-thinking skills with exceptional attention to detail.Clear written communication skills with the ability to articulate clinical rationale.Ability to work independently in a remote environment and manage competing priorities.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 Working With Us?401(k), Medical, Dental, and Vision benefitsFlexible, paid vacation policyWork in a flat organizational structure — direct access to LeadershipApply for this positionAutofill from resumeSave time by uploading your resume. (Only PDF or DOCX format supported)Upload filePreferred Location *Select...Personal InformationFirst name*Last name*Email*Phone🇺🇸+1LinkedIn URLProfileEducationAddExperienceAddResume*Drag and drop files or click to uploadSupported files: .pdf & .docx, up to 20 MBCover LetterDrag and drop files or click to uploadSupported files: .pdf & .docx, up to 20 MBADDITIONAL INFORMATIONLicense*Do you hold an active RN license?YesNoExperience*Do you have hands-on experience with DRG validation or DRG review?YesNoEqual Opportunity EmployerHelp us be an equal opportunity employerYou are requested (but not required) to fill in the personal data below. This information is used solely for government reporting and will not influence our hiring decisions.Race or ethnicitySelect...GenderSelect...Self-identification of Veteran status(Completion is voluntary and will not subject you to adverse treatment)Alaffia Health is a Government contractor subject to the Section 4212 of the Vietnam Era Veterans's Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, which requires Government contractors to take affirmative action to employ and advance in employment: (1) Disabled veterans - A veteran who served on active duty in the U.S. military and is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or was discharged or released from active duty because of a service-connected disability; (2) Recently separated veteran - A veteran separated during the three-year period beginning on the date of the veteran's discharge or release from active duty in the U.S military, ground, naval, or air service; (3) Active duty wartime or campaign badge veteran - A veteran who served on active duty in the U.S. military during a war, or in a campaign or expedition for which a campaign badge was authorized under the laws administered by the Department of Defense; (4) Armed forces service medal veteran - A veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 Fed. 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