ABOUT ALAFFIA & OUR MISSION
Every year, U.S. health plans lose billions to improper payments and
administrative waste. That wasted spending ultimately trickles down across the
healthcare ecosystem, driving up costs for plans, providers, and patients alike.
We’re here to change that paradigm.
Alaffia is a new kind of claims operations partner for health plans. Using
expert clinicians and transparent AI, we deliver deeper insights, smarter
automation, and consistently better outcomes across the entire lifecycle of
claims. With Alaffia, health plans can cut wasted spending more effectively than
ever — and provide their members the most affordable care.
We’re a high-growth, venture-backed Series B healthtech startup based in NYC and
are actively scaling our company. Join us in helping to build a healthcare
system that works better for everyone.
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.
ABOUT THE ROLE
Alaffia is seeking an experienced Clinical DRG Auditor to join our Payment
Integrity team. In this role, you will perform inpatient Diagnosis-Related Group
(DRG) validation audits and detailed clinical reviews of medical records and
claims. You will leverage your clinical expertise and deep understanding of
reimbursement, documentation standards, and coding guidelines to identify
unsupported DRGs, improve payment accuracy, and inform audit automation.
This role is ideal for an RN with hands-on experience in clinical DRG
validation, inpatient auditing, or CDI-adjacent review work.
WHAT YOU'LL BE DOING
Clinical DRG Review & Validation
Perform comprehensive clinical DRG audits on inpatient claims, including
validation of principal diagnosis, secondary diagnoses, CCs/MCCs, procedures,
sequencing, and discharge status.
Evaluate whether clinical documentation supports the billed DRG in accordance
with CMS guidelines, payer policies, and nationally accepted standards of
care.
Apply clinical judgment and clinical guidelines to interpret complex
inpatient medical records, including physician notes, labs, imaging,
procedures, and treatment plans.
Identify documentation gaps, unsupported diagnoses, and DRG upcoding or
misclassification.
Audit Documentation & Reporting
Produce clear, defensible audit findings with concise clinical rationale.
Accurately document audit determinations in Alaffia’s audit platform and
supporting tools.
Support quality assurance processes and peer review as needed.
Compliance & Policy Adherence
Maintain working knowledge of ICD-10-CM/PCS coding principles, DRG groupers
(MS-DRG, APR-DRG, AP-DRG as applicable), CMS guidance, and payer-specific
reimbursement policies.
Ensure all audit activity complies with HIPAA, regulatory requirements, and
internal SOPs.
Cross-Functional Collaboration
Collaborate with payment integrity operations, product, and engineering teams
to provide clinical insight that informs audit logic and AI-driven review
models.
Contribute to ongoing process improvements, training, and audit optimization
initiatives.
WHO YOU ARE
Required Qualifications
Active Registered Nurse (RN) license
3+ years of experience performing clinical DRG validation, inpatient clinical
review, DRG auditing, CDI review, or similar payment integrity work.
Strong ability to interpret inpatient medical records and assess clinical
validity of diagnoses and procedures.
Experience applying clinical judgment in a reimbursement or audit context.
Preferred Qualifications
Direct experience conducting DRG audits for payers, vendors, or consulting
organizations.
Working knowledge of inpatient reimbursement methodologies and hospital
billing workflows.
Familiarity with payer audit programs, pre-pay or post-pay reviews, and
appeals support.
Experience working with audit platforms, EHRs, and claims data systems.
Certifications (Preferred, Not Required)
CPC, CCS, CIC, CPMA, CCDS, CDIP, or similar clinical/coding/audit
certification.
Core Competencies
Strong analytical and critical-thinking skills with exceptional attention to
detail.
Clear written communication skills with the ability to articulate clinical
rationale.
Ability to work independently in a remote environment and manage competing
priorities.
OUR CULTURE
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.
WHAT ELSE DO YOU GET WORKING WITH US?
401(k), Medical, Dental, and Vision benefits
Flexible, paid vacation policy
Work in a flat organizational structure — direct access to Leadership