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.
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, 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

• 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 teams to design and build scalable tools and solutions that support new growth opportunities in these areas.

Requirements

• MD/DO
• Proven experience in claims auditing or payment integrity within a health plan or TPA
• Deep claims expertise with understanding of provider billing, 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, data-analytics environments, strong plus.

Salary
For New York City-based hires only: Compensation Range: $130-150 per hour base salary, subject to standard withholding and applicable taxes. Compensation finally awarded to the candidate will be commensurate with the candidate's skills and experience. Compensation ranges for candidates in locations outside of New York City may differ based on the cost of labor and such additional factors for such other locations.