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 ResponsibilitiesSupport 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 claimsConduct detailed reviews of itemized bills, medical records, and other claims data to validate coding accuracy and appropriateness of chargesWork 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.RequirementsMD/DOExperience 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 TPADeep claims expertise with an understanding of provider billing and payer operations.billing, revenue cycle management, and payment integritySolid 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.BenefitsCompensation:$130-$150 per hour. Compensation finally awarded to the candidate will be commensurate with the candidate’s skills and experience.

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