[Hiring] Clinical Itemized Bill Reviewer @Alaffia Health

Role Description

We are looking for a Clinical Itemized Bill Reviewer to join our growing Appeals and Disputes team. In this role, you will be responsible for reviewing and investigating provider disputes related to Payment Integrity findings, with a focus on high-dollar facility claims and itemized bills.

• 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

Qualifications

• 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
• At least one of the following certifications is preferred: CPC, CIC, CRC, CPMA, or equivalent
• Active RN license preferred
• 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
• Knowledge of PHI/HIPAA compliance and standards
• Strong written and verbal communication skills
• Ability to work collaboratively with Payment Integrity teams and PIA Managers

Benefits

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