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

1. 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.

2. 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.

3. 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.