Health Claims Specialist III at Orthofix – Lewisville, Texas

Why Orthofix?

Guided by our organizational values – Take Ownership | Innovate Boldly | Win Together – we collaborate closely with world-class surgeons and other partners to improve people’s quality of life. At Orthofix, we want team members who build relationships and share knowledge, challenge the status quo, and deliver results every day to help us achieve our vision to be the unrivaled partner in Med Tech.

Our global team of over 1,600 employees brings to market highly innovative, cost-effective, and user-friendly medical technologies that heal musculoskeletal pathologies for patients and the healthcare professionals who treat them. Looking to change people’s lives? Look no further.

JOB PURPOSE

The Specialist III is a highly experienced, senior-level role within the wing-to-wing revenue cycle management team for DME claims. This individual serves as an insurance payer expert, problem-solver and strategic contributor for the resolution of complex, escalated and stalled claims. The Accounts Receivable Specialist level III leads root cause analysis for denials and payer disputes, provides mentorship to level I and II collectors, and supports departmental efforts to improve workflows, optimize payer strategies and drive collections performance.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

The following are the essential functions of this position. This position may be responsible for performing additional duties and tasks as needed and assigned.

• Take ownership of complex, aged or escalated accounts requiring detailed investigation, negotiation and strategic follow-through across all payer types.
• Lead resolution of complex accounts involving prepayment audits, clinical appeals, payer escalations and refund/recoupment cases.
• Analyze payer trends and systemic denial issues; initiate internal reviews and collaborate with management to develop and implement corrective strategies.
• Serve as a subject matter expert (SME) on payer policy changes, contract interpretation, billing guidelines and compliance risks.
• Assist with the development and refinement of work instructions, standard appeal templates and escalation pathways.
• Act as a lead and mentor to level I and II Accounts Receivable Specialists, assist with training, guidance on payer processes, documentation standards and communication techniques.
• Coordinate with internal stakeholders as needed to ensure proper handling of disputed claims and revenue impacting issues.
• Participate in in payer calls or external meetings to represent the organization in resolving complex reimbursement barriers.
• Ensure accurate and thorough documentation in account records.
• Collaborate with Specialist level IIII and leadership to identify process gaps, recommend system enhancements and assist with special projects or reporting as needed.
• Consistently achieve departmental metrics and actively contribute to team performance targets and cash goals.

MINIMUM QUALIFICATIONS

The requirements listed below are representative of the education, knowledge, skill and/or ability required for this position.

Education/Certifications:

• High School Diploma or Equivalent Experience

Experience, Skills, Knowledge and/or Abilities:

• 4+ years of progressively responsible experience in Orthofix medical collections, revenue cycle, or DME claims management.
• Advanced understanding of DME billing, payer policies (Medicare, Medicare Advantage, Medicaid, Commercial payers, Litigation, Work Comp, Auto) and appeals lifecycle.
• Demonstrated experience in managing high-complexity claims, payer escalations, and cross-departmental collaboration.
• Expertise in interpreting contracts, payer fee schedules, EOBs, LCD/NCD guidelines, Clinical and reimbursement strategies.

• Strategic thinker with a strong understanding of reimbursement policy, payer operations, and healthcare regulations.
• Exceptional analytical, investigative, and documentation skills with the ability to explain and defend decisions.
• Excellent mentoring, training and leadership presence in team environments.
• Comfortable leading and participating in discussions with payers and presenting data to leadership.
• Proficient in revenue cycle systems, and Microsoft excel.
• Self-directed, accountable, and able to manage shifting priorities in a high-volume environment.

PREFERRED QUALIFICATIONS

The education, knowledge, skills and/or abilities listed below are preferred qualifications in addition to the minimum qualifications stated above.

Education/Certifications:

• Associate’s degree preferred

Additional Experience, Skills, Knowledge and/or Abilities:

• N/A

PHYSICAL REQUIREMENTS / ADVERSE WORKING CONDITIONS

The physical requirements listed in this section include but are not limited to the motor/physical abilities, skills, and/or demands required of the position in order to successfully undertake the essential duties and responsibilities of this position. In accordance with the Americans with Disabilities Act (ADA), reasonable accommodations may be made to allow qualified individuals with a disability to perform the essential functions and responsibilities of the position.

• No additional physical requirements or essential functions for this position.

DISCLAIMER

The duties listed above are intended only as representation of the essential functions of this position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. The job description does not constitute an employment agreement between the employer and employee and is subject to change at the sole discretion of the employer. Nothing in this document alters an employee’s at-will employment status.

The anticipated base hourly rate for this position is $24 - $28 per hour  plus bonus and benefits. The final pay offered to a successful candidate will be dependent on several factors that may include but are not limited to the type and years of experience within the job, the type and years of experience within the industry, education, etc.

DISCLAIMER

The duties listed above are intended only as representation of the essential functions of this position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. The job description does not constitute an employment agreement between the employer and employee and is subject to change at the sole discretion of the employer. Nothing in this document alters an employee’s at-will employment status.

We are committed to providing equal employment opportunities to all employees and applicants without regard to race (including traits historically associated with race, such as hair texture and protective hairstyles, including braids, locks, and twists), ethnicity, religion, religious creed (including religious dress and grooming practices), color, caste, sex (including childbirth, breast feeding, and related medical conditions), gender, gender identity or expression, sexual orientation, national origin, ancestry, citizenship status, uniform service member and veteran status, marital status, pregnancy, age (40 and over), protected medical condition (including cancer and genetic conditions), genetic information, disability (mental and physical), reproductive health decision-making, medical leave or other types of protected leave (requesting or approved for leave under the Family and Medical Leave Act or the California Family Rights Act), domestic violence victim status, political affiliation, or any other protected status in accordance with all applicable federal, state, and local laws.

This policy extends to all aspects of our employment practices including, but not limited to, recruiting, hiring, discipline, termination, promotions, transfers, compensation, benefits, training, leaves of absence, and other terms and conditions of employment.

Since 1980, Orthofix has evolved and grown to become one of the leading medical device companies with a spine and orthopedics focus in the world. Our newly merged Orthofix-SeaSpine organization is a leading global spine and orthopedics company with a comprehensive portfolio of biologics, innovative spinal hardware, bone growth therapies, specialized orthopedic solutions, and a leading surgical navigation system. Our products are distributed in 68 countries worldwide.

Our medical device company is headquartered in Lewisville, Texas, and has primary offices in Carlsbad, CA, and Verona, Italy. Our combined company’s global R&D, commercial and manufacturing footprint also includes facilities and offices in Irvine, CA; Toronto, Canada; Sunnyvale, CA; Wayne, PA; Olive Branch, MS; Maidenhead, UK; Munich, Germany; Paris, France; and São Paulo, Brazil.

Founded in Verona, Italy, and now headquartered in Lewisville, Texas, Orthofix is proud to be recognized as the 8th Largest Orthopedic Medical Device Company in the World by Medical Design & Outsourcing magazine. Orthofix is committed to improving patients’ lives and delivering innovative, quality-driven solutions that empower physicians and healthcare organizations to meet the needs of their patients every day.