[Hiring] Physician Advisor @Healthee

Role Description

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.

• 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.

Qualifications

• 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.

Compensation

$130-$150 per hour. Compensation finally awarded to the candidate will be commensurate with the candidate’s skills and experience.