Nurse Auditor (Medical Records Review)

About Alaffia & Our Mission

The U.S. healthcare system suffers from over $300B in improper payments each year due to fraud, waste, abuse, and processing errors. We’re on a mission to change that. To best prevent inaccurate payments, we’ve assembled a team of experienced technologists and industry-leading healthcare domain experts. The Alaffia team has alumni ranging from Amazon, Goldman Sachs, the Centers for Medicare and Medicaid Services, and other leading healthcare and financial institutions. We’re also backed by industry-leading venture capital firms!

If you want 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 you.

Our Culture

At 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. Our people are entrepreneurial by nature, problem solvers, and are passionate about what they do — both inside and outside of the office.

About the Role & What You’ll Be Doing

Alaffia is automating medical claim audits to reduce and recover the billions of dollars medical insurance companies improperly pay to medical providers each year. Health plans and auditors trust the Alaffia platform to rapidly execute post-payment claims audits.

We are looking for a Clinical Medical Bill Reviewer to join our team! Do you have experience reviewing claim forms and auditing provider documentation? Then this position is for you! You will work alongside our team to empower our clients with technology that will modernize medical claim auditing.

You will be responsible for reviewing and analyzing medical claims, patient medical records, and automatic claim audit results to help train our machines that will deliver automated audit results. You will be performing high-dollar bill reviews. Your role will be integral to your engineering teams and will help inform decisions that will shape the future of healthcare we aim to see.

Your Responsibilities

1. Evaluates each patient's medical record reviewing specific documents relating to patient treatment and billable charges, identifying services billed versus services rendered
2. Performs clinical audit/validation processes to ensure that medical record documentation and REV/HCPCS/CPT/ICD coding and billing for services rendered is complete, compliant and accurate to support optimal reimbursement
3. Complete audits to verify that the clinical documentation contained within the patient chart supports items and services included on the patient bill and identify errors or discrepancies to determine reasons for treatment, billing, payment or operations
4. and documents the rationale for all findings
5. Use the information obtained from the audit process to inform and educate the team concerning clinical reimbursement results and practices
6. Prepares and presents daily audit reports complete with findings of discrepancies or exceptions

What We’re Looking For

1. Current active clinical registered nursing license in the US (RN only)
2. Requires 3-5 plus years hands-on clinical experience across a variety of specialties and settings
3. Must have clinical documentation, medical necessity, and/or utilization review experience
4. Experience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening tools 
5. Working knowledge of provider billing guidelines, payer reimbursement policies and related industry-based standards
6. Effective oral and written communication skills
7. Effective negotiating skills and ability to work independently
8. Ability to apply clinical assessment skills to the medical record audit process and extract supportive documentation.
9. Demonstrated ability in use of personal computer and related software. Expertise in spreadsheets, word processing and data base management packages preferred; ability to learn these skills required
10. Comprehensive understanding of all related guidelines related to coding and/or billing
11. Previous background in auditing such as experience in medical record review
12. CPC certification (preferred)

What Else Do You Get Working With Us?

Competitive compensation package (cash equity)

Medical, Dental and Vision benefits

Flexible, paid vacation policy

Work in a flat organizational structure — direct access to Leadership