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Healthee

Making healthcare benefits less complex and more accessible, empowering employees to live their healthiest lives.

Physician Advisor – Managed Care Claims & Billing

GeneralGeneralContractRemoteSeniorTeam 51-200Since 2021H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

71 days ago

Salary

$130 - $150 / hour

Seniority

Senior

Postgraduate DegreeEnglish

Job Description

Physician Advisor – Managed Care Claims & Billing

Healthee

• 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.

Job 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. *

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