Physician Reviewer

About Alaffia Health

Alaffia Health is an AI-enabled claim review engine, allowing health plans to review claims fast and accurately, reducing the cost of care for all by reducing medical billing fraud, waste, and abuse. Our customers use our AI Agents to eliminate manual work, reducing administrative costs and burdens in the healthcare industry.

Alaffia Health is a Series A hyper-growth company based in New York City that has raised $18M to date from top-tier VCs like FirstMark and Anthemis.

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 facing 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 York City

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.

Our Culture

At Alaffia, we fundamentally believe that the whole is more valuable than the sum of its individual parts. 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.