Surgical AR Representative

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.
• 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.