Physician Advisor - Managed Care Claims & Billing (Contractor)
Hi, we’re Healthee.
We’re on a mission to make healthcare easy for everyone. Our AI-powered platform helps employees understand, navigate, and optimize their healthcare benefits — transforming how people access and manage care.
We’re looking for a Physician Advisor with a strong background in managed care claims, medical billing, and payer-side processes (TPA, insurance companies, etc.). In this role, you’ll bridge the clinical and financial aspects of healthcare — ensuring accurate mapping of medical services, claims, and billing logic, as well as supporting re-pricing and pre-payment processes.
You’ll report directly to our Chief Medical & Data Officer, working closely with the Growth and Data Science teams. You’ll play a key role in validating and refining Healthee’s AI-driven claims fraud, waste, and abuse detection, as well as re-pricing and pre-payment processes, ensuring our algorithms and billing logic align with real-world clinical accuracy.
We strive to be the best at what we do — and we’d love your help getting there.
Key Responsibilities
- Support re-pricing and pre-payment processes to ensure accurate claim valuation, validation, and alignment with payer rules and clinical standards.
- Review, evaluate, and investigate claims data, medical billing logic, and CPT coding to ensure billing accurately reflects the patient’s care.
- Identify and correct mismatches between clinical documentation and billing submissions to prevent denials, errors, compliance risks, and potential fraud or abuse.
- Ensure all codes accurately represent the services provided, avoiding both under- and over-billing.
- Fraud, Waste, and Abuse Detection (FWA): Identify and investigate potential FWA claims
- Conduct detailed reviews of itemized bills, medical records, and other claims data to validate coding accuracy and appropriateness of charges
- Work with insurance companies and TPAs to clarify medical necessity, address coverage discrepancies, and resolve claim disputes.
- Serve as a subject-matter expert on clinical and billing topics during audits, product reviews, and client implementations.
- Collaborate with Growth and Data Science teams to design and build scalable tools and solutions that support new growth opportunities in these areas.
Requirements
- MD/DO
- Experience with re-pricing and pre-payment review processes, including claim validation, reimbursement methodologies, and alignment with payer policies.
- Proven experience in claims auditing or payment integrity within a health plan or TPA
- Deep claims expertise with an understanding of provider billing and payer operations.billing, revenue cycle management, and payment integrity
- Solid understanding of CPT, ICD-10, HCPCS codes, and reimbursement processes.
- Strong analytical and communication skills; ability to translate medical concepts into structured business logic.
- Experience in health-tech and data analytics environments, strong plus.
Benefits
Compensation:
$130-$150 per hour. Compensation finally awarded to the candidate will be commensurate with the candidate’s skills and experience.