Surgical AR Representative

Spire Orthopedic Partners•Stamford, CT

2d•$26 - $33•Onsite

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 requires advanced knowledge of surgical coding, payer reimbursement methodologies, bundling rules, medical necessity criteria, and appeals strategy. The representative manages high-dollar, complex surgical claims, pursues payer follow-up, prepares detailed appeals, and works with coding and clinical teams to help prevent recurring denials. Spine surgery reimbursement experience, including instrumented procedures and multi-level cases, is preferred. This is a performance-driven, detail-oriented position requiring strong analytical skills and the ability to independently resolve complex reimbursement issues.

Requirements

3–5+ years of accounts receivable 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, including instrumented procedures and multi-level cases.
CPC certification.

Responsibilities

Manage aging accounts receivable for orthopedic and spine surgical claims.
Review high-dollar surgical accounts in detail.
Identify underpayments, bundling errors, and contractual discrepancies.
Escalate claims through payer reconsideration and appeals processes.
Follow up within payer filing limits and monitor timely filing and appeal deadlines.
Investigate and resolve denials involving medical necessity, bundling and NCCI edits, modifier use, global periods, downcoding, and prior authorization.
Draft 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.
Understand reimbursement for multi-level spinal fusions, instrumentation and hardware, decompression procedures, revision surgeries, and ASC versus hospital settings.
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 and identify payment variances or contractual underpayments.
Assist in recovering underpaid claims.
Maintain detailed account notes documenting follow-up actions.
Ensure appeals and follow-up actions meet compliance standards and adhere to HIPAA and payer guidelines.