Healthcare Pricing – Direct Pay Specialist
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Job Description
Healthcare pricing specialist coordinating CPT-based rates, provider negotiations, and direct payments. Frontier Direct Care delivers accessible primary care and proactive Care Navigation.
Responsibilities:
- Review clinical referrals, orders, and chart notes to verify CPT, HCPCS, and ICD-10 codes
- Identify complete episode costs, separating or bundling professional, facility/ASC, anesthesia, pathology, laboratory, and DME charges
- Contact specialist offices, imaging centers, laboratories, and surgical facilities to obtain written self-pay or prompt-pay fee schedules
- Build Provider Option Slates detailing pricing, location, availability, and payment terms for Care Navigators
- Cross-check services and CPT codes against employer or sponsor health plan guidelines and clinical criteria
- Negotiate cash rates, global surgical/procedure bundles, and Single Case Agreements with clinics, surgery centers, and hospitals
- Benchmark provider quotes against Medicare baselines, clinic fee schedules, and historical fair-market cash rates
- Serve as the pricing and billing resource for Care Navigators on complex referrals
- Troubleshoot point-of-service billing issues so patients are not asked to pay out of pocket or turned away
- Execute timely direct payments for specialist care, imaging, therapies, and outpatient procedures
Requirements:
- 2–4+ years of experience in healthcare revenue cycle, medical billing/coding, upfront patient financial counseling, surgical/procedure cost estimation, direct provider contracting, or TPA/self-funded plan pricing
- Strong working knowledge of CPT, HCPCS, and ICD-10 codes
- Ability to read a clinical order and identify which CPT codes apply
- Understanding of global surgical periods, common modifiers, and facility vs. professional billing splits
- Experience requesting or building self-pay estimates, prompt-pay discounts, fee schedules, or Single Case Agreements (SCAs)
- Comfort executing point-of-service payments via virtual credit cards, ACH, checks, or payment portals
- Experience reconciling itemized superbills and receipts
- Proven ability to negotiate with billing managers and revenue cycle directors and secure clear written rate confirmations quickly
- Ability to juggle high-volume daily task queues, including STAT same-day check-ins and multi-day pricing research, in an EHR/ticketing system
- Active coding or revenue cycle certification (CPC, CPB, CCS-P, CRCR, or equivalent) or equivalent hands-on specialty clinic/ASC financial estimation experience
- Experience in Direct Primary Care (DPC), Direct Contracting, Reference-Based Pricing (RBP), surgical bundles, or self-funded employer health plans
- Background in multi-specialty outpatient settings, including orthopedics, GI, cardiology, general surgery, advanced radiology, or outpatient surgery centers
- Bilingual English/Spanish is a plus
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