Manager - Medical Bill Review Operations
2 weeks ago
About Alaffia & Our MissionEach year, the U.S. healthcare system suffers from over $500B in wasted spending due to medical billing fraud, waste, and administrative burden. At Alaffia, we're on a mission to change that. We've assembled a team of clinicians, AI/ML engineers, and product experts to build advanced AI that finally bends the cost curve for all patients across our ecosystem. We're a high-growth, venture-backed startup based in NYC and are actively scaling our company.About the Role & What You'll Be DoingAs 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 ResponsibilitiesLead and manage a team of Payment Integrity Analysts (PIAs), providing direction, guidance, and support to ensure the accurate and efficient execution of claim review processesMonitor and evaluate team performance, conducting regular performance reviews and providing constructive feedback to drive continuous improvement that drive operational excellenceWrite and update standard operating procedures (SOPs) for various types of claim reviews, including pre-pay, post-pay, and reviews for commercial and government clientsCollaborate with cross-functional teams to develop and implement strategies for optimizing payment integrity processes and workflowsProvide ongoing training and education to PIAs to ensure compliance with industry regulations and guidelinesConduct regular audits and quality assurance checks to validate the accuracy of claim review resultsServe as a subject matter expert on healthcare reimbursement methodologies and coding guidelines, providing guidance and support to internal stakeholders as neededStay abreast of industry trends, regulatory changes, and emerging best practices in payment integrity, incorporating relevant insights into operational strategies and initiativesAct as a liaison between the PIA team and other departments within the organization, facilitating communication and alignment on shared goals and objectivesRequirements for the RoleActive Clinical license in the US (RN, APRN or above)CPC or CCS certification required; CPMA certification preferredAt least 10+ years of experience in the healthcare industry with 5+ years of hands-on clinical experience across a variety of specialties and settings5+ years experience in a leadership role with people management responsibilities, with the ability to effectively manage and motivate teamsExcellent analytical and problem-solving abilitiesThorough understanding of healthcare reimbursement methodologies and coding guidelinesMust have clinical documentation review and/or utilization review experienceExperience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening toolsWorking knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standardsEffective oral and written communication skills, detail-oriented with a focus on accuracy and qualityEffective negotiating skills and ability to work independentlyDemonstrated 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 requiredOur CultureAt 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. If you want to work alongside driven people on a mission 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 youWhat Else Do You Get Working With Us?Employer-sponsored Medical, Dental, and Vision benefitsFlexible, paid vacation policyWork in a flat organizational structure - direct access to LeadershipLI-REMOTE
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