Payer Underpayment Recover Specialist

Who we are:

Spire Orthopedic Partners is a growing national partnership of orthopedic practices that provides the support capital and operational resources physicians need to grow thriving practices for the future. As a Management Services Organization (MSO) Spire provides the infrastructure for administrative operations that allows practices to operate at their highest level so doctors can focus their efforts on what matters most patient care. Headquartered in Stamford Connecticut the Spire network spans the Northeast with more than 165 physicians 1800 employees 285 other clinical providers and 40 locations in New York Connecticut Rhode Island and Massachusetts.

What youll do:

The Payer Underpayment Recovery Specialist is responsible for identifying validating documenting and pursuing payer underpayments to ensure reimbursement is received in accordance with payer contracts fee schedules government reimbursement requirements and organizational billing expectations. This role reviews payment variances analyzes expected versus actual reimbursement prepares supporting documentation and works directly with payers to secure additional payment when underpayments are identified.

This position plays a key role in improving net collection performance reducing revenue leakage and supporting a proactive revenue cycle operating model.

Responsibilities/Duties:

• Identify potential payer underpayments by reviewing payment data contractual allowed amounts fee schedules EOBs/ERAs payer policies claim history and expected reimbursement calculations.
• Use Rivet Modernizing Medicine Athena Excel and payer portals to research reimbursement variances validate expected payment and document findings.
• Validate underpayment opportunities by comparing actual payments to contracted rates payer reimbursement terms authorization details procedure coding modifiers bundling rules and applicable payment policies.
• Research payer contracts fee schedules reimbursement methodologies and payer-specific requirements to determine whether additional payment is supported.
• Prepare clear and complete documentation packages to support payer reconsideration corrected payment requests appeals or escalation for additional reimbursement.
• Submit or coordinate submission of underpayment disputes reconsideration requests appeals and payer inquiries within required payer timeframes.
• Track underpayment cases from identification through resolution including payer response payment outcome write-off determination and escalation status.
• Maintain Excel-based spreadsheets and trackers to monitor underpayment opportunities dollars identified dollars recovered payer response aging and root cause trends.
• Partner with billing coding payment posting payer collections contracting and revenue integrity teams to resolve payment discrepancies and prevent repeat underpayments.
• Identify trends by payer CPT code modifier provider practice location system or contract term and escalate recurring issues for operational or contractual resolution.
• Support reporting on underpayment recovery revenue impact payer trends aged cases overturn rates and process improvement opportunities.

Systems and Tools

• Rivet for expected reimbursement analysis variance identification payer trend review and reimbursement validation.
• Modernizing Medicine for claim charge payment coding provider and patient account review.
• Athena for claim payment payer response account follow-up and documentation review when applicable.
• Microsoft Excel and spreadsheets for tracking reconciliation analysis reporting and documentation of underpayment recovery activity.
• Payer portals and clearinghouse tools for claim status remittance review reconsideration submission appeals and payer correspondence.

Who you are:

Qualifications:

• Experience in healthcare revenue cycle payer collections reimbursement analysis contract variance review payment posting denials or revenue integrity.
• Experience using Rivet Modernizing Medicine Athena Excel and spreadsheet-based trackers strongly preferred.
• Intermediate to advanced Excel proficiency required including the ability to use formulas filters pivot tables sorting data validation reconciliations and large spreadsheet trackers to identify and document reimbursement variances.
• Strong understanding of EOBs ERAs payer contracts fee schedules CPT/HCPCS codes modifiers claim forms payer policies and reimbursement methodologies.
• Ability to analyze expected versus actual reimbursement and clearly explain payment variances.
• Strong written communication skills with the ability to prepare payer-facing documentation and escalation summaries.
• Detail-oriented with strong organizational skills and the ability to manage multiple underpayment cases through resolution.
• Experience with orthopedic surgical ASC or specialty physician billing preferred.
• Knowledge of commercial Medicare Medicaid workers compensation bundled payment and value-based arrangements preferred.
• Bachelors degree preferred; relevant healthcare revenue cycle or reimbursement experience may be considered in lieu of a degree.

What we offer:

• Excellent growth and advancement opportunities
• Dynamic environment
• Access to a diverse network of practitioners
• Broad infrastructure of tools and programs to enhance the employee experience
• Competitive Compensation
• Generous PTO
• Benefits package: health dental vision 401(k) etc.

We are an equal-opportunity employer. Qualified Applicants are considered for positions and are evaluated without regard to actual or perceived race color creed religion national origin ancestry citizenship status age sex or gender (including pregnancy childbirth and related medical conditions) gender identity or gender expression (including transgender status) sexual orientation marital status military service and veteran status physical or mental disability protected medical condition as defined by applicable state or local law genetic information or any other characteristic protected by applicable federal state or local laws and ordinances (referred to as protected characteristics).