Surgical AR Representative

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 Surgical AR & Denials Management Representativeis responsible forthe resolution of complex accounts receivable and payer denials related to orthopedic and spine surgical services. This role requires advanced knowledge of surgical coding payer reimbursement methodologies bundling rules medical necessity criteria and appeals strategy.

The representative will manage high-dollar complex surgical claims aggressively pursue payer follow-up draft detailed appeals and partner with coding and clinical teams to prevent recurring denials. Preference will be given to candidates with experience in spine surgery reimbursement including instrumented procedures and multi-level cases.

This is a performance-driven detail-oriented role requiring strong analytical skills and the ability to independently resolve complex reimbursement issues.

Responsibilities/Duties:

• Manage aging accounts receivablespecificto orthopedic and spine surgical claims.

• Perform detailed review of high-dollar surgical accounts.

• Identifyunderpayments bundling errors and contractual discrepancies.

• Escalate claims through payer reconsideration andappealsprocesses.

• Maintaintimelyfollow-upin accordance withpayer filing limits.
• Investigate and resolve denials including:
  • Medical necessity
  • Bundling and NCCI edits
  • Modifier denials
  • Global period denials
  • Downcoding
  • Prior authorization issues
• Draft comprehensive evidence-based appeals including supporting documentation.
• Track denial trends and escalate systemic issues to management.
• Participatein payerpeer-to-peer or escalation discussions as needed.
• Understand reimbursement for complex orthopedic and spine procedures including:
  • Multi-level spinal fusions
  • Instrumentation and hardware
  • Decompression procedures
  • Revision surgeries
  • ASC vs hospital reimbursement differences
• Review operative reports tovalidatecoding and appeal strategy.
• Collaborate withcodingteam on documentation improvement opportunities.
• Review payer contracts tovalidateexpected reimbursement.
• Identifypayment variances and contractual underpayments.
• Assistin recovery of underpaid claims.
• Monitortimelyfiling and appeal deadlines.
• Maintaindetailed account notes reflecting follow-up actions.
• Ensureappeals and follow-up actionsmeetcompliance standards.
• Adhere to HIPAA and payer guidelines.

Who you are:

• 35 years of AR follow-up and denial management experience in physician practice or surgical specialty environment.
• Demonstrated experience with orthopedic surgical claimsrequired.
• Spine surgery reimbursement experience strongly preferred.
• Strong knowledge of CPT ICD-10 HCPCS NCCI edits and modifier usage.
• Experience with commercial Medicare and Workers Compensation payers.
• Ability to analyze EOBs and payer remittance advice in detail.
• CPC certification is preferred but notrequired.
• Advanced surgical reimbursement knowledge
• Strong written appeal drafting skills
• Analytical and problem-solving ability
• Persistence and follow-through
• Detail orientation
• Ability to manage high-volume high-dollar accounts
• Independent decision-making capability

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).

The final pay offered to a successful candidate will be dependent on several factors that may include but are not limited to the type and years of experience within the job the type of years and experience within the industry education etc.