Surgical AR Representative

Spire Orthopedic Partners•Stamford, CT

About The Position

The Surgical AR & Denials Management Representative resolves complex accounts receivable issues 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, drafts detailed appeals, and partners with coding and clinical teams to prevent recurring denials. Experience with spine surgery reimbursement, including instrumented procedures and multi-level cases, is preferred. This is a performance-driven, detail-oriented role requiring strong analytical skills and the ability to independently resolve complex reimbursement issues. Spire Orthopedic Partners is a national partnership of orthopedic practices and a Management Services Organization (MSO) that provides administrative infrastructure and operational resources to its practices. Headquartered in Stamford, Connecticut, its network spans the Northeast and includes 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 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.
Strong written appeal-drafting skills.
Analytical and problem-solving ability, persistence, follow-through, and attention to detail.
Ability to manage high-volume, high-dollar accounts.
Ability to make decisions independently.

Nice To Haves

Spine surgery reimbursement experience, including instrumented procedures and multi-level cases.
CPC certification.
Advanced surgical reimbursement knowledge.

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 denials, global period denials, downcoding, and prior authorization issues.
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.
Understand reimbursement for complex orthopedic and spine procedures, including 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.
Maintain detailed account notes reflecting follow-up actions.
Ensure appeals and follow-up actions meet compliance standards and adhere to HIPAA and payer guidelines.