Healthcare Pricing, Direct Pay Specialist

This is a fully remote position, open to applicants in Texas.

📋 Description

• Assess clinical referrals, orders, and chart notes to confirm the correct CPT, HCPCS, and ICD-10 codes.

• Determine all relevant billing elements for specialist consultations, diagnostics, imaging, injections, and outpatient procedures.

• Distinguish or combine professional/physician fees, facility/ASC fees, anesthesia, pathology, labs, and DME to avoid unexpected bills.

• Reach out to specialist offices, imaging centers, labs, and surgical facilities to gather written self-pay and prompt-pay fee schedules.

• Develop Provider Option Slates that include pricing, location, availability, and payment terms for Care Navigators.

• Verify services and CPT codes against employer/sponsor health plan guidelines and clinical criteria to ensure cash-pay eligibility.

• Negotiate reasonable cash rates, global surgical/procedure bundles, and Single Case Agreements with clinic practice managers, surgery centers, and hospital financial counselors.

• Compare provider quotes to Medicare benchmarks, clinic fee schedules, and historical fair-market cash rates.

• Act as the pricing and billing expert for Care Navigators regarding complex referrals.

• Resolve point-of-service billing concerns to ensure members are not required to pay out of pocket or are turned away.

• Facilitate prompt direct payments for specialist care, imaging, therapies, and procedures while reconciling payment documentation.

⛳️ 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 proficiency in CPT, HCPCS, and ICD-10 codes.

• Capability to interpret a clinical order and identify corresponding CPT codes.

• Knowledge of global surgical periods, common modifiers, and the distinctions between facility and professional billing.

• Practical experience with cash-pay/self-pay processes, including self-pay estimates, prompt-pay discounts, fee schedules, or Single Case Agreements (SCAs).

• Comfort in processing point-of-service payments via virtual credit cards, ACH, checks, or payment portals, along with reconciling itemized superbills/receipts.

• Demonstrated ability to negotiate with billing managers and revenue cycle directors, obtaining written rate confirmations efficiently.

• Capacity to handle high-volume daily task queues, including same-day check-ins and multi-day pricing research, within an EHR/ticketing system.

• Active coding or revenue cycle certification (CPC, CPB, CCS-P, CRCR, or equivalent) or equivalent hands-on experience in specialty clinic/ASC financial estimation.

• 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 environments such as orthopedics, GI, cardiology, general surgery, advanced radiology, or outpatient surgery centers.

• Bilingual proficiency in English and Spanish is an advantage.

🏝️ Benefits

• Competitive salary and compensation package.

• Opportunities for professional development and training.

• Comprehensive health benefits and wellness programs.

• Flexible work schedule and remote work options.

• Supportive and inclusive work environment.