[Hiring] Surgical AR Representative @Spire Orthopedic Partners

Role Description

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.

• 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.

Qualifications

• 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.
• 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 not required.
• 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.

Benefits

• 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.