VP, Payment Integrity Solutions

Role Description

We are seeking a seasoned clinical Payment Integrity (PI) executive to join Alaffia as Vice President of Clinical Claims Solutions. In this role, you will own the strategy, growth, and delivery of Alaffia's clinical PI offerings across our health plan client base. You will lead a team of implementation and client-facing specialists, serve as a senior executive sponsor for our most strategic accounts, and partner closely with Product, Engineering, and Sales leadership to shape the direction of our AI-powered platform. This is a defining leadership role for a high-growth company tackling $570B+ in industry waste.

Key Responsibilities

• Executive Leadership & Strategy:
  • Define and execute the go-to-market and delivery strategy for Alaffia's clinical claims solutions.
  • Set the vision for how our agentic AI platform serves health plan clients across pre-pay, post-pay, clinical editing, DRG review, upcoding detection, and overpayment recovery.
  • Own the roadmap for scaling our PI offerings and translating it into measurable client and business outcomes.
• Client Executive Sponsorship:
  • Serve as the senior executive point of contact for Alaffia's most strategic health plan clients.
  • Build and sustain C-suite and VP-level relationships, lead executive business reviews, and ensure clients realize ongoing and expanding value from Alaffia's solutions.
  • Navigate complex escalations and serve as a trusted long-term partner.
• Team Building & Development:
  • Recruit, lead, and mentor a high-performing team of Directors and implementation/client success specialists.
  • Foster a culture of clinical excellence, accountability, and client obsession.
  • Define team structure, role clarity, and career development pathways as the organization scales.
• Revenue Growth & Expansion:
  • Partner with Sales and Solutions leadership to drive new logo acquisition and expand existing accounts.
  • Bring credibility and executive presence to late-stage sales pursuits, strategic demos, and contract negotiations.
  • Identify and champion opportunities to deepen AI/agentic tool adoption within client environments.
• Cross-Functional Partnership:
  • Act as the senior voice of the client and clinical PI practitioner across internal stakeholder groups — Product, Engineering, Operations, and Clinical.
  • Influence the product roadmap based on real-world client feedback and emerging industry trends.
  • Ensure tight alignment between delivery and commercial commitments.
• Operational Excellence:
  • Establish scalable processes for implementation, onboarding, and ongoing client support.
  • Define and track KPIs for clinical accuracy, client satisfaction, savings delivery, and team performance.
  • Drive continuous improvement across all client-facing workflows.
• Industry Thought Leadership:
  • Represent Alaffia externally at industry forums, conferences, and client advisory sessions.
  • Stay ahead of regulatory developments (CMS guidelines, state/federal compliance), evolving PI challenges (FWA, coordination of benefits, unbundling), and AI innovation in healthcare claims.

Qualifications

• 12+ years in healthcare payment integrity, with a significant portion in senior leadership.
• Deep hands-on expertise in clinical claim review, medical necessity, coding validation (DRG, CPT), and improper payment identification.
• Demonstrated success leading and scaling client-facing or operational teams in a health plan, PI vendor, or related environment.
• Proven executive presence — comfortable presenting to C-suite audiences, leading strategic negotiations, and representing a company externally.
• Track record of driving material savings outcomes, building high-performing teams, and scaling PI programs.
• Strong clinical background (RN, clinical reviewer, or equivalent) combined with the ability to speak credibly about AI-enabled tools, claims platforms, and automation.
• Excellent communication and executive storytelling skills; able to translate complex clinical and technical concepts for diverse audiences.

Requirements

• Experience with AI or agentic AI tools in healthcare claims; prior leadership at a company leveraging transparent clinical AI.
• Background spanning health plan operations, utilization management, appeals, or Special Investigations Unit (SIU).
• Knowledge of regulatory environments and common PI challenges including upcoding, unbundling, and coordination of benefits.
• Bachelor's or advanced degree in nursing, healthcare administration, or a related field. Relevant certifications (CCS, RHIA, CPC) are a plus.

Benefits

• Competitive Compensation
• Medical, Dental, and Vision benefits
• Flexible, paid vacation policy
• Work in a flat organizational structure — direct access to Leadership