Surgical AR Representative

Spire Orthopedic Partners•Stamford, CT

12h

About The Position

The Surgical AR & Denials Management Representative resolves complex accounts receivable and payer denials related to orthopedic and spine surgical services. The role calls for advanced knowledge of surgical coding, payer reimbursement methodologies, bundling rules, medical necessity criteria, and appeals strategy. The representative manages high-dollar surgical claims, pursues payer follow-up, drafts detailed appeals, and works with coding and clinical teams to help prevent recurring denials. Experience with spine surgery reimbursement, including instrumented procedures and multi-level cases, is preferred. This performance-driven, detail-oriented role requires strong analytical skills and the ability to independently resolve complex reimbursement issues. Spire Orthopedic Partners is a growing national partnership of orthopedic practices and a Management Services Organization (MSO). It provides administrative infrastructure, support, capital, and operational resources so physicians can focus on patient care. Headquartered in Stamford, Connecticut, its network spans the Northeast, with more than 165 physicians, 1,800 employees, 285 other clinical providers, and 40 locations in New York, Connecticut, Rhode Island, and Massachusetts.

Requirements

3–5+ years of AR follow-up and denial management experience in a physician practice or surgical specialty environment.
Demonstrated experience with orthopedic surgical claims.
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.
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.

Nice To Haves

Spine surgery reimbursement experience, strongly preferred.
CPC certification, preferred but not required.

Responsibilities

Manage aging accounts receivable for orthopedic and spine surgical claims.
Perform detailed reviews of high-dollar surgical accounts.
Identify underpayments, bundling errors, and contractual discrepancies.
Escalate claims through payer reconsideration and appeals processes.
Maintain timely follow-up in accordance with payer filing limits.
Investigate and resolve denials involving medical necessity, bundling and NCCI edits, modifier usage, global periods, downcoding, and prior authorization.
Draft comprehensive, evidence-based appeals with supporting documentation.
Track denial trends and escalate systemic issues to management.
Participate in payer peer-to-peer or escalation discussions as needed.
Apply reimbursement knowledge to multi-level spinal fusions, instrumentation and hardware, decompression procedures, revision surgeries, and ASC-versus-hospital reimbursement differences.
Review operative reports to validate coding and appeal strategy.
Collaborate with the coding team on documentation improvement opportunities.
Review payer contracts to validate expected reimbursement.
Identify payment variances and contractual underpayments, and assist in recovering underpaid claims.
Monitor timely-filing and appeal deadlines.
Maintain detailed account notes reflecting follow-up actions.
Ensure appeals and follow-up actions meet compliance standards.
Adhere to HIPAA and payer guidelines.