State Licensed Physician Advisor

Job Summary

A company is looking for a Physician Advisor - Managed Care Claims & Billing (Contractor).

Key Responsibilities

• Support re-pricing and pre-payment processes to ensure accurate claim valuation and alignment with payer rules
• Review and investigate claims data, medical billing logic, and CPT coding for accuracy
• Identify and correct mismatches between clinical documentation and billing submissions to prevent errors and compliance risks

Required Qualifications

• MD/DO degree
• Experience with re-pricing and pre-payment review processes, including claim validation
• 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
• Solid understanding of CPT, ICD-10, HCPCS codes, and reimbursement processes