Clinical Subject Matter Expert

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, charges, and codes fit together

• Experience giving structured, consistent feedback on written work, such as annotating or scoring drafts against a rubric

• The ability to turn clinical judgment into clear written requirements and criteria that engineers and product managers can act on

• Comfort working inside a product team where processes are still being built, ideally at a startup or technology company

• Curiosity about how AI models learn and where they go wrong, and the directness to tell a team when a statement isn't good enough and why

Extra Credit if you have:

• Experience in revenue integrity, utilization review, or clinical documentation improvement for hospitals or health systems

• Familiarity with the No Surprises Act or Independent Dispute Resolution

• Experience working with 835/837 claims data or evaluating AI-generated content

Why You’ll Love Working Here We’re a collaborative, low-ego team on a mission to make healthcare reimbursement fairer for providers. While we primarily hire around our core hubs–Los Angeles and New York–we remain open to exceptional talent outside those regions. Remote and hybrid flexibility varies by role and team, and is outlined in each job description. If you’re excited by solving complex problems and making a real-world impact, we’d love to hear from you. Benefits Include:

• Competitive compensation, including equity

• Full health, dental, and vision coverage

• Retirement savings plan through 401(k)

• Flexible time off

• Opportunities for company-wide connection and events

Ready to Make an Impact? We’re building something meaningful; and we want you on the team. Bring your ideas, curiosity, and drive, and let’s transform healthcare reimbursement together.

Employment Information Work Authorization Candidates must be authorized to work in the United States without current or future employer sponsorship. Equal Employment Opportunity Pivotal Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other legally protected status. Reasonable Accommodations Pivotal Health provides reasonable accommodations for qualified individuals with disabilities in accordance with applicable laws. If you need assistance during the application or interview process, please let us know. Background Checks Employment is contingent upon successful completion of applicable background checks, where permitted by law. At-Will Employment Employment with Pivotal Health is at-will and may be terminated by either party at any time, with or without cause or notice, in accordance with applicable law.