Job Description

About Alaffia & Our Mission

Each 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

We are seeking a clinically trained, detail-oriented Doctor of Medicine (MD) to support and lead clinical audit functions for our health plan partners. The ideal candidate will have experience performing clinical reviews of facility claims on behalf of payers, including DRG validation, readmission reviews, short stay assessments, and other medical necessity determinations.

This individual will play a critical role in evaluating inpatient and outpatient claims and delivering defensible clinical determinations. You will collaborate closely with internal audit, product, and AI engineering teams to improve our AI-driven review tools and audit logic. This is a high-impact, fast-paced role suited for someone excited to innovate in healthcare while working at the intersection of clinical review and technology.

What You’ll Be Doing

• Perform clinical reviews of facility claims across inpatient and outpatient settings using payer-side criteria and policies.
• Conduct claim-level assessments including DRG validation, short stay, readmission, medical necessity, and other utilization management reviews.
• Leverage nationally recognized clinical guidelines and plan-specific policies to make defensible clinical determinations.
• Collaborate with cross-functional teams —product managers, AI engineers, auditors—to provide clinical feedback that enhances the accuracy and usability of Alaffia’s AI tools.
• Participate in QA, case discussions, and escalated appeal reviews.
• Stay current on regulatory and payer guidelines to ensure compliance and review integrity.
• Support new product initiatives and help train internal teams on clinical and audit protocols as needed.
• Advocate for the use of generative AI in healthcare by educating internal teams, external clients, and partners about its transformative potential.

What We’re Looking For

• MD degree (active license preferred but not required).
• Prior patient facin g clinical practice experience in a hospital setting
• Minimum 3 years of clinical review experience on the payer side, with direct experience auditing medical claims across a range of areas, including:
• DRG validation
• Short stay
• Medical necessity
• Readmissions
• Prior authorization
• Utilization Management
• Strong knowledge of CMS guidelines, InterQual/MCG, ICD-10/CPT coding, and facility billing standards.
• Proven experience communicating clinical decisions in audit reports, rebuttals, and appeals.
• Comfortable using and providing feedback on healthcare technology and AI tools.
• A passion for AI and a curiosity about how large language models can be applied to solve healthcare challenges.
• Preferably based in the New Yor k area for a hybrid engagement but open to remote candidates.

What Else Do You Get Working With Us?

• Competitive base salary
• Company stock options
• Fully covered employer-sponsored healthcare
• Unlimited PTO
• Work in a flat organizational structure — direct access to Executive team members

Please note: Alaffia Health does not provide employment sponsorships at this time

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