SlipstreamJobs tracks this role from the company's public career site. Apply directly on the employer's site.
Pivotal Health is a technology platform helping healthcare providers navigate complex reimbursement landscapes and recover underpaid claims through AI-driven workflows. The company manages out-of-network claim arbitration under the No Surprises Act Independent Dispute Resolution (IDR) process and is expanding from medical groups into hospitals and health systems.
In this role, you will own the end-to-end expansion into facility billing (institutional claims). You will serve as the facility-side expert, translating complex reimbursement knowledge into shipped product capability and working alongside Product as an advisor and decision-maker.
Key responsibilities:
- Define how Pivotal evaluates, prices, and presents inpatient and outpatient facility claims in IDR; decide scope, claim types, and exclusions
- Quarterback the expansion across product, engineering, data, operations, client success, sales, and legal/compliance; own the plan, owners, dependencies, and timeline
- Define product requirements by translating facility-billing and IDR expertise into build-ready specs: 837I/835 ingestion, claim-level vs. line-level logic, DRG, revenue code and HCPCS handling, batching rules, and QPA analysis
- Develop the arbitration position framework and templates for facility offers and briefs, presenting case mix, acuity, scope of services, teaching status, market position, and prior contracted rates
- Analyze 837I and 835 data (CARC/RARC codes, adjustments, bundled payments, outliers, carve-outs) to spot underpayment patterns and identify disputable claims
- Support market expansion by joining sales conversations and client onboarding with hospital revenue cycle, managed care, and finance leaders; build credibility with CFOs and patient financial services teams
Requirements:
- 10+ years in hospital or health-system revenue cycle, managed care or payer contracting, reimbursement, or denials/underpayment recovery, with hands-on institutional claims experience
- Working command of inpatient reimbursement (MS-DRG / APR-DRG, per diem, case rates, outliers) and outpatient reimbursement (APC/OPPS, fee schedules, percent-of-charge, packaging)
- Fluency with revenue codes, HCPCS/CPT, ICD-10-CM/PCS, UB-04, and bill types
- Fluency with 837I and 835 files, including adjustment logic and remit interpretation
- Direct experience with the No Surprises Act, IDR, or payer disputes over out-of-network facility reimbursement, or demonstrated ability to ramp fast
- Ability to write persuasive, evidence-based arguments such as appeals, payer negotiation memos, and arbitration briefs
- Track record of leading cross-functional work without formal authority, writing sharp product requirements, and operating in a startup or scale-up environment
Extra credit: HealthTech or healthcare-related technology experience; experience at an IDR entity, payer QPA/OON pricing team, or underpayment-recovery firm; contract modeling or chargemaster knowledge; familiarity with state surprise-billing arbitration programs.
