Director, Payment Integrity

### **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. ### **About the Role** As the **Director, Payment Integrity**, you'll own the strategy, performance, and scale of Alaffia's Payment Integrity review programs — including Itemized Bill Review, Medical record review, DRG Validations, and other related clinical and PI review functions. 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 Doing** #### **Program Strategy & Leadership** - Own the overall strategy, roadmap, and operating model for the Payment Integrity review program, including Itemized Bill Review (IBR) and facility/DRG audit workstreams - Lead and develop a team of Managers, providing them the coaching, structure, and resources to run high-performing review teams - Set org-wide performance standards and targets for audit accuracy, throughput, SLA adherence, and findings quality, and hold managers accountable to them - Build the multi-quarter capacity plan for the review organization, forecasting headcount, hiring needs, and workload against client growth - Represent Payment Integrity in company-wide planning, budgeting, and leadership discussions #### **Clinical & Audit Quality Governance** - Serve as the senior clinical authority for audit quality across the program, setting the standards that Managers and reviewers are held to - Establish escalation paths for high-complexity, high-dollar, or high-risk audit disputes, and make final calls when needed - Ensure 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 programs - Own the audit quality assurance framework, including calibration across reviewers/managers and periodic program-level quality reviews - Partner with Product/Engineering on how AI and automation get incorporated into review workflows, ensuring clinical accuracy and defensibility are preserved as the program scales #### **Program & Workflow Ownership** - Own the end-to-end operating model connecting operations (intake, documentation requests, provider outreach) with clinical review execution, in partnership with Payment Integrity Operations leadership - Approve and continuously refine SOPs across all audit workflows: intake, review methodology, documentation, escalation, and appeals support - Identify systemic bottlenecks across the program and drive cross-functional initiatives to improve cycle time, capacity, and reviewer efficiency - Own SLA performance across the full review queue and ensure contractual commitments are met at scale across m…