Clinical Itemized Bill Reviewer (Appeals and Disputes)

About Alaffia & Our Mission 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. 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 Role We 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 Responsibilities Review and investigate provider disputes related to Payment Integrity audit findings Review high-dollar facility claims and itemized bills for potential coding, billing, and payment inaccuracies Analyze original audit findings, UB-04s, itemized bills, medical records, clinical documentation, and supporting provider materials Compare itemized bills and claim forms against medical records and clinical documentation to validate charges and assess the accuracy of billed services Determine whether Payment Integrity findings should be upheld, modified, or overturned based on available evidence Research and apply relevant clinical, coding, billing, national, and payer-specific guidelines Develop clear, accurate, and well-supported written responses to provider disputes Identify inconsistencies between claims billed, clinical documentation, coding, and health plan payments Validate coding, billing, and clinical findings using applicable code sets and reimbursement guidelines Clearly document case findings, rationale, and final determinations Manage a high-volume queue of provider disputes while maintaining accuracy, quality, and timely resolution Partner closely with PIA Managers and other Payment Integrity team members to review complex cases and ensure consistent decision-making Identify trends and recurring issues across provider disputes and share insights that can improve Payment Integrity audit processes Maintain compliance with PHI/HIPAA requirements and applicable healthcare regulations and standards Who You Are 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or a related healthcare claims function Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s Deep knowledge of medical billing, coding, clinical documentation, and insurance claims Experience evaluating whether billed services and charges are supported by medical records and clinical documentation Strong understanding of relevant coding and reimbursement systems, including CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code sets Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines Ability to analyze complex clinical and claims information and translate findings into clear, defensible written responses Strong attention to detail and ability to manage a high-volume case queue while maintaining accuracy and quality At least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalent Active RN license preferred Experience working for a health plan, insurance company, or Payment Integrity organization preferred Experience with high-dollar facility bill review and complex claim auditing preferred Knowledge of PHI/HIPAA compliance and standards Strong written and verbal communication skills Ability to work collaboratively with Payment Integrity teams and PIA Managers Our Culture Alaffia 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 package Medical, Dental and Vision benefits Flexible, paid vacation policy Work in a flat organizational structure — direct access to Leadership