Physician Advisor – Managed Care Claims & Billing

This is a fully remote position, open to applicants in United States.

📋 Description

• Assist in the re-pricing and pre-payment procedures to guarantee precise claim valuation, validation, and compliance with payer guidelines and clinical standards.

• Analyze, assess, and scrutinize claims data, medical billing logic, and CPT coding to ensure that billing accurately represents the patient's care received.

• Detect and rectify discrepancies between clinical documentation and billing submissions to avoid denials, inaccuracies, compliance issues, and possible fraud or abuse.

• Confirm that all codes accurately depict the services rendered, preventing both under- and over-billing.

• Fraud, Waste, and Abuse Detection (FWA): Recognize and investigate potential FWA claims.

• Perform thorough examinations of itemized bills, medical records, and other claims data to verify coding accuracy and the appropriateness of charges.

• Collaborate with insurance companies and TPAs to clarify medical necessity, tackle coverage discrepancies, and resolve claim disputes.

• Act as a subject-matter expert on clinical and billing topics during audits, product assessments, and client implementations.

• Partner with Growth and Data Science teams to create and develop scalable tools and solutions that foster new growth opportunities in these domains.

⛳️ Requirements

• MD/DO

• Experience with re-pricing and pre-payment review processes, including claim validation, reimbursement methodologies, and alignment with payer policies.

• Demonstrated experience in claims auditing or payment integrity within a health plan or TPA.

• Extensive claims expertise with a solid understanding of provider billing and payer operations, including billing, revenue cycle management, and payment integrity.

• Strong knowledge of CPT, ICD-10, HCPCS codes, and reimbursement processes.

• Excellent analytical and communication skills; capable of translating medical concepts into organized business logic.

• Experience in health-tech and data analytics environments is a significant plus.

🏝️ Benefits

• **Compensation**:***$130-$150 per hour.* The final compensation awarded to the candidate will be based on their skills and experience.