Medical Claims Review Manager jobs in New York

About Alaffia & Our Mission

The U.S. healthcare system suffers from over $300B in improper payments each year due to fraud, waste, abuse, and processing errors. We’re on a mission to change that. To best prevent inaccurate payments, we’ve assembled a team of experienced technologists and industry-leading healthcare domain experts. The Alaffia team has alumni ranging from Amazon, Goldman Sachs, the Centers for Medicare and Medicaid Services, and other leading healthcare and financial institutions. We’re also backed by industry-leading venture capital firms!

If you want to make a major impact at the core of U.S. healthcare by implementing the latest in cutting-edge technologies, then we’d like to meet you.

Our Culture

At Alaffia, we fundamentally believe that the whole is more valuable than the sum of its individual parts. Further to that point, we believe a diverse team of individuals with various backgrounds, ideologies, and types of training generates the most value. Our people are entrepreneurial by nature, problem solvers, and are passionate about what they do — both inside and outside of the office.

About the Role & What You’ll Be Doing

As a Payment Integrity Manager at Alaffia, you'll play a crucial role in overseeing and optimizing our Payment Integrity Analysts (PIA) team's performance to ensure accurate and efficient bill reviews. Drawing on your expertise in healthcare operations and working in a payer environment, you'll guide day-to-day operations, track performance metrics, and implement strategies to enhance operational efficiency and effectiveness. 

With your clinical background and industry knowledge, you'll lead by example, demonstrating best practices in bill review processes and advocating for ongoing training and development opportunities for the team. Additionally, you'll be responsible for developing and documenting standard operating procedures (SOPs) for various types of claim reviews and payer types. Your contributions will be instrumental in ensuring the success and growth of our Payment Integrity team, ultimately driving value for our clients and helping Alaffia achieve its operational goals.

Your Responsibilities

• Lead and manage a team of Payment Integrity Analysts (PIAs), providing direction, guidance, and support to ensure the accurate and efficient execution of claim review processes
• Monitor and evaluate team performance, conducting regular performance reviews and providing constructive feedback to drive continuous improvement that drive operational excellence
• Write and update standard operating procedures (SOPs) for various types of claim reviews, including pre-pay, post-pay, and reviews for commercial and government clients
• Collaborate with cross-functional teams to develop and implement strategies for optimizing payment integrity processes and workflows
• Provide ongoing training and education to PIAs to ensure compliance with industry regulations and guidelines
• Conduct regular audits and quality assurance checks to validate the accuracy of claim review results
• Serve as a subject matter expert on healthcare reimbursement methodologies and coding guidelines, providing guidance and support to internal stakeholders as needed
• Stay abreast of industry trends, regulatory changes, and emerging best practices in payment integrity, incorporating relevant insights into operational strategies and initiatives
• Act as a liaison between the PIA team and other departments within the organization, facilitating communication and alignment on shared goals and objectives

What We’re Looking For

• Active Clinical license in the US (RN, APRN or above)
• CPC or CCS certification required, CPMA certification preferred
• At least 10 years of experience in the healthcare industry with 5 years of hands-on clinical experience across a variety of specialties and settings
• 5 years experience in a leadership role with people management responsibilities, with the ability to effectively manage and motivate teams
• Excellent analytical and problem-solving abilities
• Thorough understanding of healthcare reimbursement methodologies and coding guidelines
• Must have clinical documentation review and/or utilization review experience
• Experience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening tools
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards
• Effective oral and written communication skills, detail-oriented with a focus on accuracy and quality
• Effective negotiating skills and ability to work independently
• Demonstrated ability in the use of personal computer and related software. Expertise in healthcare analytics tools, software platforms, spreadsheets, word processing, and database management packages preferred; ability to learn these skills required

What Else Do You Get Working With Us?

Employer-sponsored Medical, Dental, and Vision benefits

Flexible, paid vacation policy

Work in a flat organizational structure — direct access to Leadership

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