Director, Payment Integrity

Role Description

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 multiple client programs.
• Client & Executive Relationship Management
  • Serve as a senior point of contact for client executives on Payment Integrity program performance, escalations, and strategic account decisions.
  • Own client-facing reporting on program performance — accuracy, savings/findings, throughput, and trends — and present at executive business reviews.
  • Lead client escalations, appeals discussions, and provider dispute resolution for the most complex or highest-stakes cases.
  • Partner with Sales/Managed Services on scoping new client programs, staffing models, and program design during Implementations & onboarding.
• Team Building & Organizational Development
  • Hire, develop, and retain a strong bench of Managers, building a leadership pipeline within the review organization.
  • Establish career paths, training curricula, and audit playbooks that support reviewer and manager growth across the org.
  • Build a culture of clinical rigor, accountability, and continuous improvement across the entire Payment Integrity organization.
  • Own root-cause analysis and corrective action processes for program-level quality or client escalation trends, reporting findings and remediation plans to leadership.
• Operational Governance & Reporting
  • Own the KPI framework for the Payment Integrity organization: audit accuracy, throughput, SLA compliance, findings per case, appeal overturn rate, and client savings/impact metrics.
  • Establish and lead the reporting cadence to company leadership on program health, growth, quality trends, and capacity.
  • Stay ahead of coding guideline updates, CMS policy changes, and payer requirements, ensuring the org adapts proactively.
  • Contribute Payment Integrity domain expertise to company-level strategic initiatives, including product roadmap input and AI/automation strategy.

Qualifications

• 8+ years of experience in medical bill review, facility coding, clinical auditing, or payment integrity, including 4+ years leading managers or running a multi-team review organization.
• Deep expertise across a broad range of Payment Integrity review types, including but not limited to UB-04/facility claim auditing, Itemized Bill Review (IBR), with extensive experience with coding accuracy, confirming billed charges, and comparing claims against supporting medical records across multiple payer types and lines of business (LOBs).
• Proven track record owning program-level KPIs (accuracy, throughput, SLA, quality) and driving measurable improvement at scale.
• Strong working knowledge of national coding guidelines: CPT, ICD-10-CM/PCS, HCPCS, DRGs, APCs, revenue codes, and POS codes.
• Experience serving as a senior point of contact for client executives, including presenting performance data and leading escalations.
• Demonstrated ability to build and scale teams — hiring, developing managers, and establishing career pathing and training programs.
• Excellent written and verbal communication skills, with experience presenting to executive audiences (internal and client-side).
• Knowledge of HIPAA/PHI compliance standards and payer-specific audit policies.
• Active RN license or higher-level clinical license strongly preferred; equivalent senior clinical/coding leadership background will be considered.

Preferred Qualifications

• Prior experience at a health plan, payment integrity vendor, or managed care organization in a director or senior leadership capacity.
• Experience owning or heavily influencing AI/ML-assisted review workflows or model validation processes.
• Background across multiple audit types — DRG validation, readmissions review, itemized bill review, or coding audits.
• Familiarity with revenue cycle operations and hospital billing workflows.
• At least one relevant certification (CPC, CIC, CRC, CPMA, or equivalent).
• Experience operating in a high-growth startup environment, building process and structure from limited existing scaffolding.

Core Competencies

• Program owner: You think in terms of the whole program — capacity, quality, client outcomes, and P&L — not just a single team.
• People developer: You build leaders, not just manage individual contributors; you invest in Managers the way they invest in reviewers.
• Executive communicator: You're comfortable owning the room in a client business review or a leadership planning session.
• Clinical authority: You set the bar for audit methodology and coding accuracy across the entire organization.
• Systems thinker: You design for scale — processes, tooling, and organizational structure that hold up as volume grows.
• Adaptable builder: You thrive in a fast-paced startup environment where you're building the plane while flying it.

Benefits

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

Company Description

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.