Surgical AR Representative

Spire Orthopedic Partners•Stamford, CT

6d•$26 - $33

About The Position

The Surgical AR & Denials Management Representative is responsible for the 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.

Requirements

3–5+ years of AR follow-up and denial management experience in physician practice or surgical specialty environment.
Demonstrated experience with orthopedic surgical claims required.
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 is preferred but not required.

Responsibilities

Manage aging accounts receivable specific to orthopedic and spine surgical claims.
Perform detailed review 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 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.
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
ASC vs hospital reimbursement differences
Review operative reports to validate coding and appeal strategy.
Collaborate with coding team on documentation improvement opportunities.
Review payer contracts to validate expected reimbursement.
Identify payment variances and contractual underpayments.
Assist in recovery of 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.