Clinical Itemized Bill Reviewer (Appeals and Disputes)

Summary

Alaffia Health is a healthtech company that helps health plans reduce improper payments and administrative waste through expert clinicians and AI-powered claims operations. The Clinical Itemized Bill Reviewer will investigate provider disputes involving Payment Integrity findings, review high-dollar facility claims and itemized bills, and determine whether findings should be upheld, modified, or overturned. The role also involves documenting defensible decisions, managing a high-volume case queue, and collaborating with Payment Integrity teams to ensure consistent outcomes.

Responsibilities

• Review and investigate provider disputes related to Payment Integrity audit findings
• Review high-dollar facility claims and itemized bills for potential coding, billing, and payment inaccuracies
• Analyze original audit findings, UB-04s, itemized bills, medical records, clinical documentation, and supporting provider materials
• Compare itemized bills and claim forms against medical records and clinical documentation to validate charges and assess the accuracy of billed services
• Determine whether Payment Integrity findings should be upheld, modified, or overturned based on available evidence
• Research and apply relevant clinical, coding, billing, national, and payer-specific guidelines
• Develop clear, accurate, and well-supported written responses to provider disputes
• Identify inconsistencies between claims billed, clinical documentation, coding, and health plan payments
• Validate coding, billing, and clinical findings using applicable code sets and reimbursement guidelines
• Clearly document case findings, rationale, and final determinations
• Manage a high-volume queue of provider disputes while maintaining accuracy, quality, and timely resolution
• Partner closely with PIA Managers and other Payment Integrity team members to review complex cases and ensure consistent decision-making
• Identify trends and recurring issues across provider disputes and share insights that can improve Payment Integrity audit processes
• Maintain compliance with PHI/HIPAA requirements and applicable healthcare regulations and standards

Skills

• * **Active RN license required**
• 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or a related healthcare claims function
• Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings
• Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s
• Deep knowledge of medical billing, coding, clinical documentation, and insurance claims
• Experience evaluating whether billed services and charges are supported by medical records and clinical documentation
• Strong understanding of relevant coding and reimbursement systems, including CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code sets
• Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines
• Ability to analyze complex clinical and claims information and translate findings into clear, defensible written responses
• Strong attention to detail and ability to manage a high-volume case queue while maintaining accuracy and quality
• Knowledge of PHI/HIPAA compliance and standards
• Strong written and verbal communication skills
• Ability to work collaboratively with Payment Integrity teams and PIA Managers
• *This position requires current authorization to work in the United States. Unfortunately, we are not in a position to sponsor work visas at this time.*
• At least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalent
• Experience working for a health plan, insurance company, or Payment Integrity organization preferred
• Experience with high-dollar facility bill review and complex claim auditing preferred

Qualifications

Must Haves

• * **Active RN license required**
• 3+ years of experience in Payment Integrity, medical bill review, clinical auditing, claims auditing, or a related healthcare claims function
• Hands-on experience reviewing and responding to provider appeals, disputes, reconsiderations, or challenges to Payment Integrity findings
• Strong experience performing itemized bill reviews and auditing facility claims, including UB-04s
• Deep knowledge of medical billing, coding, clinical documentation, and insurance claims
• Experience evaluating whether billed services and charges are supported by medical records and clinical documentation
• Strong understanding of relevant coding and reimbursement systems, including CPT, ICD-10, HCPCS, revenue codes, DRGs, APCs, and other applicable code sets
• Experience researching and applying national and/or payer-specific coding, billing, and reimbursement guidelines
• Ability to analyze complex clinical and claims information and translate findings into clear, defensible written responses
• Strong attention to detail and ability to manage a high-volume case queue while maintaining accuracy and quality
• Knowledge of PHI/HIPAA compliance and standards
• Strong written and verbal communication skills
• Ability to work collaboratively with Payment Integrity teams and PIA Managers
• *This position requires current authorization to work in the United States. Unfortunately, we are not in a position to sponsor work visas at this time.*

Nice to Haves

• At least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalent
• Experience working for a health plan, insurance company, or Payment Integrity organization preferred
• Experience with high-dollar facility bill review and complex claim auditing preferred

Benefits

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