Physician Advisor - Managed Care Claims & Billing (Contractor)

Healthee

4d•$130 - $150

About The Position

Healthee is seeking a Physician Advisor with a strong background in managed care claims, medical billing, and payer-side processes. The role involves bridging the clinical and financial aspects of healthcare, ensuring accurate mapping of medical services, claims, and billing logic, and supporting re-pricing and pre-payment processes. The Physician Advisor will 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 algorithms and billing logic align with real-world clinical accuracy.

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.

Nice To Haves

Experience in health-tech and data analytics environments

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.
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.