Clinical Itemized Bill Reviewer (Appeals and Disputes)

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 RoleWe are looking for a Clinical Itemized Bill Reviewer to join our growing Appeals and Disputes team. In this role, you will be responsible for reviewing and investigating provider disputes related to Payment Integrity findings, with a focus on high-dollar facility claims and itemized bills.You will review and analyze itemized bills, UB-04 claim forms, medical records, clinical documentation, coding information, and original Payment Integrity audit findings to determine whether disputed findings should be upheld, modified, or overturned.This role is ideal for someone with hands-on experience in Payment Integrity, medical bill review, and provider appeals or disputes. You will use your clinical, coding, and auditing expertise to investigate disputed findings, apply relevant clinical and coding guidelines, and develop clear, well-supported responses to provider disputes.You will work closely with our Payment Integrity team and PIA Managers to ensure accurate, consistent, and defensible outcomes across a high volume of cases.Your ResponsibilitiesReview and investigate provider disputes related to Payment Integrity audit findingsReview high-dollar facility claims and itemized bills for potential coding, billing, and payment inaccuraciesAnalyze original audit findings, UB-04s, itemized bills, medical records, clinical documentation, and supporting provider materialsCompare itemized bills and claim forms against medical records and clinical documentation to validate charges and assess the accuracy of billed servicesDetermine whether Payment Integrity findings should be upheld, modified, or overturned based on available evidenceResearch and apply relevant clinical, coding, billing, national, and payer-specific guidelinesDevelop clear, accurate, and well-supported written responses to provider disputesIdentify inconsistencies between claims billed, clinical documentation, coding, and health plan paymentsValidate coding, billing, and clinical findings using applicable code sets and reimbursement guidelinesClearly document case findings, rationale, and final determinationsManage a high-volume queue of provider disputes while maintaining accuracy, quality, and timely resolutionPartner closely with PIA Managers and other Payment Integrity team members to review complex cases and ensure consistent decision-makingIdentify trends and recurring issues across provider disputes and share insights that can improve Payment Integrity audit processesMaintain compliance with PHI/HIPAA requirements and applicable healthcare regulations and standardsWho You AreActive RN license required3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or a related healthcare claims functionHands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findingsStrong experience performing itemized bill reviews and auditing facility claims, including UB-04sDeep knowledge of medical billing, coding, clinical documentation, and insurance claimsExperience evaluating whether billed services and charges are supported by medical records and clinical documentationStrong understanding of relevant coding and reimbursement systems, including CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code setsExperience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelinesAbility to analyze complex clinical and claims information and translate findings into clear, defensible written responsesStrong attention to detail and ability to manage a high-volume case queue while maintaining accuracy and qualityAt least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalentExperience working for a health plan, insurance company, or Payment Integrity organization preferredExperience with high-dollar facility bill review and complex claim auditing preferredKnowledge of PHI/HIPAA compliance and standardsStrong written and verbal communication skillsAbility to work collaboratively with Payment Integrity teams and PIA ManagersOur 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 LeadershipApply for this positionAutofill from resumeSave time by uploading your resume. (Only PDF or DOCX format supported)Upload filePersonal 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 have an active RN License?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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