Clinical Subject Matter Expert

Pivotal Health•New York, NY

2d•$125,000 - $147,000

About The Position

Pivotal Health is hiring a Clinical Subject Matter Expert to provide clinical judgment for position statements on increasingly complex facility claims. Embedded within Product, this role works closely with Product and Engineering to define what makes an argument persuasive and defensible, and to help shape how the company’s AI model learns from expert review. The position reports directly to the Product Lead. The role reviews model-drafted position statements, assesses their credibility and clinical reasoning, and converts expert decisions into annotations, evaluation criteria, and clear product requirements. It also determines the clinical and billing context needed for each claim so statements can accurately describe care and defend the offer. This is an hands-on product role rather than a consulting engagement, with clinical expertise incorporated into the product on an ongoing basis.

Requirements

Clinical background, most often nursing, with at least 5 years of experience in clinical documentation, denials, or appeals.
Hands-on experience writing or reviewing appeals, denial responses, or clinical arguments intended to persuade a payer, with specific outcomes to discuss.
Working knowledge of facility billing, coding, and reimbursement, including how claims, charges, and codes fit together.
Experience providing structured, consistent feedback on written work, such as annotating or scoring drafts against a rubric.
Ability to turn clinical judgment into clear written requirements and criteria that product managers and engineers can act on.
Comfort working within a product team where processes are still being built.
Curiosity about how AI models learn and where they fail, and willingness to clearly explain when a statement is inadequate and why.
Authorization to work in the United States without current or future employer sponsorship.

Nice To Haves

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.
Experience at a startup or technology company.

Responsibilities

Review model-drafted position statements for facility claims, assess credibility, and identify weak clinical reasoning or inadequate descriptions of services.
Define standards for strong position statements and translate them into guidance for Product and Engineering.
Annotate and label statements consistently to train the model, and track quality over time.
Design evaluation criteria and test sets, run evaluations as the model and templates change, and report results.
Determine the clinical and billing details needed for each claim type, and write requirements for how Product collects and uses that context.
Participate in Product and Engineering planning and reviews, provide clinical expertise, and ground decisions in denials and appeals practice.
Gather feedback from reviewers and operations and client-facing teams about why statements win or lose, and translate recurring patterns into product improvements.
Explain facility-side coding, billing, and reimbursement nuances, including bundled charges and billing code sourcing, to ensure product requirements reflect actual practice.