ABOUT PIVOTAL HEALTH
Pivotal Health is the leading technology platform that helps healthcare providers get paid fairly in an increasingly complex reimbursement landscape.
Today, many providers face persistent underpayment from health insurance companies, despite delivering high-quality care. While processes like IDR (Independent Dispute Resolution) were designed to promote fairness, they’re often administrative-heavy, time-consuming, and difficult to navigate without the right tools.
Pivotal Health combines software, data, and service into a seamlessly integrated, AI-driven platform that simplifies these complex reimbursement workflows. We help providers efficiently dispute underpaid claims, reduce administrative burden, and recover the reimbursement they’re entitled to; without adding more work to already stretched teams.
Our full-service IDR solution is just the starting point. We’re building solutions that enable providers to operate with clarity, control, and confidence across the reimbursement journey.
ABOUT THE ROLE
We're looking for a Clinical Subject Matter Expert to own the clinical judgment behind our position statements as we take on more complex facility claims. You'll work side by side with Product and Engineering and shape how our model learns what a persuasive, defensible argument looks like. This role reports directly to our Product Lead.
The work is hands-on. You'll read the position statements our model drafts, decide what a reviewer would accept or reject, and turn those calls into annotations, evaluation criteria, and clear requirements for the team. You'll also work out what clinical and billing context we need to gather for each claim, so the statement can describe the care delivered and defend our offer.
This is an embedded role, not a consulting engagement. You'll sit inside Product, and your expertise will show up in the product every day. If you've spent your career in denials and appeals and want to see that judgment built into software that does the work at scale, this is a great seat.
WHAT YOU’LL DO
- Review position statements: Read the statements our model drafts for facility claims, judge what a reviewer would find credible, and flag where the clinical reasoning is thin or the services provided are described poorly.
- Own the clinical standard for a strong statement: Define what good looks like for describing the care delivered and defending our offer, and turn it into guidance Product and Engineering can build against.
- Annotate to train the model: Label and annotate statements consistently so the model keeps learning from expert judgment, and track how quality changes over time.
- Build and run evaluations: Design the criteria and test sets we use to measure statement quality, run them as the model and templates change, and report what moved.
- Define what context we gather: Work out which clinical and billing details we need for each claim type, and write clear requirements for how Product collects and uses them.
- Partner with Product and Engineering: Join planning and reviews as the clinical voice, answer questions quickly, and keep decisions grounded in how denials and appeals actually work.
- Bring in feedback from the field: Take what reviewers and our operations and client-facing teams tell us about why statements win or lose, and turn recurring patterns into product improvements.
- Extend your expertise across facility claims: Help the team understand the coding, billing, and reimbursement nuances on the facility side, such as bundled charges and billing code sourcing, so requirements reflect reality.
WHO YOU ARE
- A clinical background, most often nursing, with 5+ years of experience in clinical documentation, denials, or appeals
- Hands-on experience writing or reviewing appeals, denial responses, or clinical arguments meant to persuade a payer, with specific outcomes you can walk us through
- Working knowledge of facility billing, coding, and reimbursement, including how claims,…