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 CPT, HCPCS, and ICD-10 codes.

• Determine total episode costs, distinguishing or grouping professional, facility/ASC, anesthesia, pathology, laboratory, and DME charges.

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

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

• Verify 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.

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

• Act as the pricing and billing resource for Care Navigators on intricate referrals.

• Resolve point-of-service billing issues to ensure patients are not requested to pay out of pocket or turned away.

• Facilitate prompt direct payments for specialist care, imaging, therapies, and outpatient procedures.

⛳️ Requirements

• 2–4+ years of experience in the healthcare revenue cycle, medical billing/coding, upfront patient financial counseling, surgical/procedure cost estimation, direct provider contracting, or TPA/self-funded plan pricing.

• Strong understanding of CPT, HCPCS, and ICD-10 codes.

• Ability to interpret a clinical order and identify applicable CPT codes.

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

• Experience in requesting or developing self-pay estimates, prompt-pay discounts, fee schedules, or Single Case Agreements (SCAs).

• Proficient in executing point-of-service payments through virtual credit cards, ACH, checks, or payment portals.

• Familiarity with reconciling detailed superbills and receipts.

• Demonstrated ability to negotiate with billing managers and revenue cycle directors and obtain clear written rate confirmations quickly.

• Capacity to manage high-volume daily task queues, including STAT 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 financial estimation experience in specialty clinics/ASCs.

• 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 a plus.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Opportunities for professional development and continuing education.

• Flexible work arrangements and a supportive work environment.