PhysicianAdvisor-ManagedCareClaims&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. *