KAREN MCWHORTER
Louisville,KY
Summary
Accomplished and energetic Healthcare Specialist with a solid history of achievement in the Healthcare Industry. I am a motivated leader and collaborator with strong organizational skills and abilities. Areas of expertise under the Healthcare Umbrella include: Recovery Credit Balance Resolution Analyst, A/R Billing & Follow Up, Payment Processing Specialist, Claims Review and Customer Service for both inpatient and outpatient facilities.
Overview
33
33
years of professional experience
Work History
Medicare Recovery Resolution Analyst (remote)
Optum Inc / UnitedHealth Group
Eden Prairie, MN
09.2025 - Current
- Demonstrated strong analytical, investigative, and problem-solving capabilities to drive effective decision-making.
- Executed comprehensive audits of resolution processes to uphold organizational compliance standards.
- Utilized advanced knowledge of CAP, Facets, Cosmos, ORS, ISET, USP/Cirrus, and Doc360 to support claims processing and auditing functions.
- Conducted comprehensive reviews of medical records to ensure accuracy and compliance.
- Utilized ICD-9, ICD-10, and CPT codes to ensure accurate medical billing and compliance.
Recovery/Resolution Representative (Remote)
Optum Inc/UnitedHealth Group
Eden Prairie, MN
08.2021 - 09.2025
- Resolved escalated concerns from internal and external teams by providing clear explanations and solutions.
- Analyzed correspondence across platforms such as Doc DNA, WAND, PIQ & Maces to ensure accurate case selection for downstream processing teams.
- Created and revised job aids to enhance team performance and streamline processes.
- Trained and assisted team members.
- Assigned daily tasks to team members in absence of Team Lead.
Credit Resolutions Analyst
Optum Inc/Medsynergies
Louisville, KY
02.2019 - 08.2021
- Resolved discrepancies in accounts with unallocated payments and overstated contractuals.
- Utilized various reports to identify and research variances and errors, implementing corrections to maintain financial integrity.
- Evaluated and reconciled patient and client accounts to address unidentified cash and credits.
- Analyze both credit and debit balance accounts implementing necessary works.
- Prepare and submit Medicare Balance Detail Report and Certification Pages on a quarterly basis.
- Maintain documentation for all communications, adjustments and refunds for retrieval and tracking purposes.
- Met and exceeded company standards and guidelines for quality in service delivery.
- Provided excellent customer service by prioritizing tasks and effectively managing multiple responsibilities.
Cash Posting & Reimbursement Specialist
Optum In/MedSynergies
Louisville, KY
10.2017 - 02.2019
- Oversaw preparation and distribution of daily reports to ensure timely information flow.
- Oversaw payment processing operations confirming that deductibles and copays were accurately recorded for each member.
- Monitored and upheld high-quality production standards to enhance operational efficiency.
A/R Billing & Enrollment Specialist
Optum Inc/MedSynergies
Louisville, KY
07.2010 - 10.2017
- Managed the correction and resubmission of primary and secondary insurance claims to facilitate efficient claims processing.
- Engaged with insurance payers on a daily basis to address denial issues, ensuring timely claims resolution.
- Engaged with Kentucky Medicaid to analyze and address denied claims, ensuring Managed the correction and resubmission of primary and secondary insurance claims to facilitate efficient claims processing.
- Address denied claims ensuring compliance with regulations.
- Analyzed appeals and grievances to ensure accurate claim resolutions.
- Facilitated appeal coordination in accordance with company policy and directed submissions to the appropriate department.
- Monitored and enforced policies and procedures to consistently meet service level agreements and turnaround expectations.
Medicare Billing & Enrollment Specialist II
Humana,Inc.
Louisville, KY
10.1993 - 07.2010
- Analyze accounts, research, and maintain reports and error trend any existing variances
- Responsible for solving issues from beginning to end, including correction of coding errors, coordinating with payers, following up with patients/clients, and following up with insurance companies either by phone, email, or websites.
- Appeal and resubmit unresolved invoices to insurance carriers
- Handled escalated calls/emails and backed up leadership with applicable management duties.
- Trained and Coached team members as needed
Education
Degree - Human Services Management/Criminal Science
University of Phoenix
Louisville, KY10-2019
High School Diploma -
Central High School
Louisville, KY01-1988
Skills
- Advanced claims processing
- ICD-10 coding
- Compliance auditing
- Medical billing
- Data analysis
- Quality assurance
Timeline
Medicare Recovery Resolution Analyst (remote)
Optum Inc / UnitedHealth Group
09.2025 - Current
Recovery/Resolution Representative (Remote)
Optum Inc/UnitedHealth Group
08.2021 - 09.2025
Credit Resolutions Analyst
Optum Inc/Medsynergies
02.2019 - 08.2021
Cash Posting & Reimbursement Specialist
Optum In/MedSynergies
10.2017 - 02.2019
A/R Billing & Enrollment Specialist
Optum Inc/MedSynergies
07.2010 - 10.2017
Medicare Billing & Enrollment Specialist II
Humana,Inc.
10.1993 - 07.2010
Degree - Human Services Management/Criminal Science
University of Phoenix
High School Diploma -
Central High School