Healthcare Pricing & Direct Pay Specialist

About Frontier Direct Care & The Role

Frontier Direct Care is transforming healthcare delivery by combining accessible primary care with proactive, white-glove Care Navigation. Through our Direct Pay (Cash Pay) coordination model, we arrange and pay for specialist consultations, diagnostic imaging, outpatient therapies, and surgical procedures upfront-bypassing the traditional insurance claim grind so our members receive faster, friction-free care.

We are seeking a detail-oriented Healthcare Pricing & Direct Pay Specialist to join our Pricing & Direct Pay pod. Sitting at the intersection of medical coding (CPT/HCPCS), provider rate negotiation, and Date-of-Service (DOS) payment execution, you will partner closely with our Care Navigators.

When a member needs specialist care, advanced imaging, physical therapy, or an outpatient procedure, you will translate the clinical order into accurate CPT codes, source and negotiate upfront self-pay or bundled pricing with clinics and facilities, verify plan cash-pay eligibility, and execute timely direct payments so the member walks into their appointment with zero billing friction.

Key Responsibilities

• CPT Code Verification & Upfront Cash Pricing
• Translate Orders into Accurate CPT Breakdowns: Review clinical referrals, orders, and chart notes to verify exact CPT, HCPCS, and ICD-10 codes across specialist visits, diagnostics, imaging (with/without contrast), injections, and outpatient procedures.
• Identify Full Episode Costs (Unbundled vs. Bundled): Anticipate all associated billing components before a patient is scheduled-separating or bundling professional/physician fees, facility/ASC fees, anesthesia, pathology, labs, and DME so there are no surprise bills after the visit.
• Source Self-Pay Quotes & Provider Options: Contact specialist offices, imaging centers, labs, and surgical facilities to obtain written self-pay/prompt-pay fee schedules and build clear Provider Option Slates (pricing, location, availability, and payment terms) for Care Navigators.
• Verify Plan Cash-Pay Eligibility: Cross-check requested services and CPT codes against employer/sponsor health plan guidelines (SPDs) and clinical criteria to confirm cash-pay eligibility before funds are committed.
• Complex Care, Bundled Pricing & Single Case Agreements (SCAs)
• Negotiate All-Inclusive Rates & SCAs: Partner with clinic practice managers, surgery centers, and hospital financial counselors to negotiate fair cash rates, global surgical/procedure bundles, and Single Case Agreements (SCAs).
• Benchmark Pricing: Evaluate provider quotes against Medicare baselines, existing clinic fee schedules, and historical fair-market cash rates to ensure cost-effective stewardship for employer sponsors.
• Cross-Functional Collaboration with Care Navigation
• Serve as the go-to pricing and billing resource for Care Navigators on ad hoc and complex referrals.
• Troubleshoot live point-of-service billing issues when a clinic front desk is unfamiliar with direct/cash-pay coordination, ensuring the patient is never asked to pay out of pocket or turned away.

Required Qualifications

• 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 (e.g., knowing an endoscopy or MRI with contrast involves more than a single base code).
• Hands-on familiarity with Cash-Pay / Self-Pay processes:
• Experience requesting or building self-pay estimates, prompt-pay discounts, fee schedules, or Single Case Agreements (SCAs).
• Comfort executing point-of-service payments (virtual credit cards, ACH, check/portal payments) and reconciling itemized superbills/receipts.
• Confident Phone & Written Negotiator: Proven ability to get past front-desk gatekeepers, speak the language of billing managers and revenue cycle directors, and secure clear written rate confirmations quickly.
• High Operational Urgency & Organization: Able to juggle high-volume daily task queues (STAT same-day check-ins alongside multi-day pricing research) in an EHR/ticketing system without dropping details.

Preferred Qualifications

• 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 (orthopedics, GI, cardiology, general surgery, advanced radiology, or outpatient surgery centers).
• Bilingual (English/Spanish) is a plus.

About the company