Pharmacy 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 and pharmacy benefits - transforming how people access medications, manage chronic conditions, and make informed care decisions.
We're looking for a Pharmacy Advisor with a strong background in care management, pharmacy billing, and payer-side processes (PBM, TPA, or insurance companies). In this role, you'll bridge the clinical, pharmaceutical, and financial aspects of healthcare.
You'll report directly to our Chief Medical & Data Officer, working closely with the Growth and Data Science teams to continuously test, measure, learn, and innovate. You'll play a key role in validating and refining Healthee's AI-driven Fraud, Waste and Abuse (FWA) 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 and audit pharmacy claims, billing logic and coding to ensure accuracy and compliance.
• Fraud, Waste and Abuse Detection (FWA): Identify and investigate potential FWA claims
• Identify and correct mismatches between formulary data, pharmacy claims, and plan documentation Ensure all drug and clinical codes accurately represent covered medications and utilization rules, avoiding both under- and over-billing.
• Conduct detailed reviews of itemized bills, medical records, and other claims data to validate coding accuracy and appropriateness of charges
• Serve as a subject-matter expert on pharmacy and billing topics during audits, product reviews, and client implementations.
• Work with PBMs, TPAs, and insurance partners to clarify clinical and billing requirements, address discrepancies, and optimize care management processes.
• Collaborate with Growth and Data teams to design and build scalable tools and solutions that drive smarter drug coverage modeling and support new growth opportunities.

Requirements

• PharmD
• Experience in pharmacy benefits, billing, or payer-side operations (PBM / TPA / insurance).
• Strong understanding of drug billing systems, coding, and pharmacy reimbursement processes.
• Experience with U.S. healthcare and pharmacy benefit structures, formulary management, or drug utilization review.
• Excellent analytical and communication skills; ability to translate pharmaceutical data into structured, actionable business logic.
• Experience in health-tech, data-analytics environments, or pharmacy automation projects - a 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.