Facility Billing Specialist

About the Role

Pivotal Health manages out-of-network claim arbitration under the No Surprises Act Independent Dispute Resolution (IDR) process. Today we serve medical groups and professional billing. We are expanding into hospitals and health systems, which brings institutional (UB-04 / 837I) claims, a different reimbursement logic, and a different case to make to an arbitrator.

You will own that expansion end to end. You will be the facility-side expert in the room and the person who turns open questions into shipped capability. You will work alongside Product as an advisor and decision-maker, run the workstreams, and keep leadership informed of progress and risk.

What You’ll Do

• Be the facility billing authority. Define how Pivotal evaluates, prices, and presents inpatient and outpatient facility claims in IDR. Decide what is in scope, which claim types we take first, and what we turn away.

• Quarterback the expansion. Own the plan, owners, dependencies, and timeline across product, engineering, data, operations, client success, sales, and legal/compliance. Communicate status and risks to leadership and escalate early.

• Define product requirements. Work alongside our Product team to translate facility-billing and IDR knowledge into clear, build-ready requirements: 837I/835 ingestion and parsing, claim-level vs. line-level logic, DRG, revenue code and HCPCS handling, batching rules, and QPA analysis.

• Develop the arbitration position. Build the framework and templates for facility offers and briefs: how to present case mix, acuity, scope of services, teaching status, market position, and prior contracted rates, and how to respond to the payer's QPA.

• Make sense of the data. Work with 837I and 835 data (CARC/RARC codes, adjustments, bundled payments, outliers, carve-outs). Spot underpayment patterns and decide which claims are worth disputing.

• Support the market. Join sales conversations and client onboarding with hospital revenue cycle, managed care, and finance leaders, and hold credibility with CFOs and patient financial services teams.

Who You Are

• 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 the ability to show you can ramp fast.

• Ability to write persuasive, evidence-based arguments such as appeals, payer negotiation memos, and arbitration briefs.

• A 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 Experience

• Experience working in HealthTech or healthcare-related technology environments

• Experience at an IDR entity, a payer QPA/OON pricing team, or an underpayment-recovery firm.

• Contract modeling or chargemaster knowledge; familiarity with state surprise-billing arbitration programs.

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

Employment Information