Facility Billing Specialist

Alt; New York (NY); Hybrid; USD 150,000 - 230,000; Full time

Benefits offered by this job

Equity

Health benefits

401(k)

Remote/hybrid flexibility

Job summary

Pivotal Health is transforming healthcare reimbursement by expanding our IDR platform to hospitals and health systems. You will own the expansion end-to-end, serving as the facility-side expert and turning open questions into shipped capabilities.

Collaborate with Product, engineering, data, and operations to define clear IDR-related requirements and strategic plans. Lead cross‑functional work in a startup/scale‑up setting and participate in market-facing discussions as a credible authority.

Qualifications

• 10+ years in hospital or health-system revenue cycle with institutional claims experience.

Responsibilities

• Be the facility billing authority: define how inpatient/outpatient facility claims are evaluated, priced, and presented in IDR; decide what is in scope and which claims to take.
• Quarterback the expansion: own plan, owners, dependencies, and timeline across product, engineering, data, operations, client success, sales, and legal/compliance; report progress and risks to leadership.
• Define product requirements: translate facility-billing and IDR knowledge into build-ready requirements (837I/835 ingestion, parsing, DRG, revenue code handling, batching, QPA analysis).
• Develop the arbitration position: create frameworks and templates for facility offers/briefs; how to present case mix, acuity, scope of services, and responses to payer QPA.
• Make sense of the data: work with 837I/835 data, CARC/RARC adjustments, outliers; identify underpayment patterns and disputes worth pursuing.
• Support the market: join sales/client onboarding with hospital revenue cycle, managed care, and finance leaders.

Skills

Experience in hospital revenue cycle

Inpatient/Outpatient reimbursement

Revenue codes / HCPCS / CPT / ICD-10-C

837I and 835 data handling

No Surprises Act / IDR experience

Persuasive, evidence-based writing

Cross-functional leadership in startup

Job description

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

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 keep leadership informed of progress and risk.

• 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.

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.