KARENA WRATHER
Dallas,TX
Summary
Seeking a challenging organization which i can obtain new skills and utilize my present abilities. work ethic and dedication. I'm a Highly-motivated Highly-motivated Detail-oriented Business Analyst employee with desire to take on and master new challenges. I'm knowledgeable. analytical, and personable with excellent problem solving skills. I Adept at working effectively unsupervised . I desire employment where I can add value to the organization that's in need of great collaboration, interpersonal, multitasking abilities.
Overview
16
16
years of professional experience
Work History
Processing Representative Annuities
New York Life Insurance Co
Dallas, TX
10.2022 - Current
- Transact routine finical & non-financial activity on client accounts wit both speed and accuracy within regulatory guidelines
- Articulate basic information in functional area and compose accurate agent and client correspondence
- Compose accurate agent and client correspondence on request as well as articulate basic information in the functional area
- Develop knowledge and skills to process more complex transactions over time
- Assist team members daily complete work in order to meed department and regulatory standards
- Effective decision makin based on comprehensive care analysis
- Demonstrate valuable interpersonal skills
- Deliver on brand purpose to enhance customer service experience during every interaction
Business Analyst 2
Centene Corp - Aline Staffing
Dallas, TX
02.2023 - 05.2023
- Coordinating appeals activities in order to ensure compliance with state and federal regulations and accrediting bodies
- Collect, organize and track information in order to facilitate and expedite member appeals
- Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Petcare reviews for cases that did not meet criteria
- Gather, analyze and report verbal and written information regarding member and provider clinical appeals including information follow up
- Prepare response letters for member and provide clinical appeals and ensure letters are compliant with State and NCQA standards.
- Maintain files and logs for all appeals
- Coordinate with Medical Director's to clarify medical determinations or clinical rationale
- Maintain current knowledge of NCQA and state regulations
- Coordinate Fair Hearings with carious internal department and agencies
- Review large volume of claims to determine if they were processed appropriately. If processed incorrectly, will need to identify root cause. Propose resolution and monitor till updated. Once updated, will be required to price out the claims and send for reprocessing.
- · Review Trended issues to determine root cause and identify system inefficiencies for processing claims
- Review Account Receivables received from providers, document root cause and provide feedback based on state guidelines and provider contract
Accounts Receivable Analyst
SCP Health - Dallas, TX
Dallas, TX
11.2018 - 10.2022
- Prepare reports management to include but not limited to denial and rejection trend reports and facility analysis Corrected, completed and processed claims per payer rejection and denial codes- ensure reimbursement goals and days in AR are maintained or achieved
- Investigated billing discrepancies claim denials, no response claims, monitor trends and resolve payor issues and implemented effective solutions to resolve concerns and prevent future problems
- Knowledge of all State Specifics: Appeals Guidelines, Timely filing Guidelines, Recipient Identification Numbers,
- Paper/Electronic Claims, EDI Reports {loops/Segments} Special Provision, Acceptable/Unacceptable Documents, Balance Billing
- Provide team with Trends, information regarding payor mandates and issues that could affect/halt/alter revenue for the company
- Prepare appeals relating to past timely filing, medical necessity, underpayment of invoices, and other various denials, in a timely manner, in order to achieve monthly cash goals
- Working /Explanation of Benefits to ensure proper reimbursement of claims and reports any payer trends or problems. Accessed Portals for true denial reasons
- Submitting Appeals /medical records for payment reconsideration through Avality, Navinet and, Amisys System
- Process Medicare, Medicaid, BCBS and Managed Care (third party payors) applications simultaneous to hospital privileging process
- Created job aid for provider updates in Avality, Navinet and Amisys System for BCBS providers
Provider Enrollment Specialist
SCP-Health - Dallas, TX
Dallas, Texas
07.2015 - 11.2018
- Act as primary contact for Provider Enrollment regarding provider-related claim denials
- Process Medicare, Medicaid, BCBS and Managed Care (third party payors) applications simultaneous to hospital privileging process and timely claim filing limits and billing requirements
- Work directly with the Provider Enrollment Supervisor to ensure timely enrollment with managed care plans to maximize reimbursement and minimize patient complaints related to participating status
- To ensure the integrity of the revenue is preserved Document and keep accurate account of all approval information into CredStream so that the billing company can be notified to release claims through provider number (PIN) assignment
- Updated with Billing carriers Work with SCP Managed Care to ensure timely enrollment with managed care plans to maximize reimbursement and minimize patient complaints related to participation status
- Submit appeals and send providers Medicaid & Healthcare Partnership approval attestation letters, license to allow claims to reprocess for payment Submit registration info via spreadsheet or form as needed for Medicaid HMO products and keep current
- Document all registration submissions and notes in Sales Force- Run PBI reports, Review carrier and industry websites, newsletters, provider manuals etc
- To assure thorough understanding of industry standards and changes state-specific info and determine if we need to submit a change at the variant level
- Requesting corrections revision and update master provider enrollment packets / updates on taxonomy codes, Provider Specialty in NPPES, Billing group NPI TAX id# per State Medicaid, Commercial carriers
- Perform out of state write offs for non-border-enrolled providers
- Front end rejections
- Identifying billing discrepancies and implemented effective solutions to resolve trends and prevent future problems.
- ED and HM CAR view Research claim logic issues and find most recent payor specific 837-P, 837-I ANSI Companion Guides CMS-1500 Billing Guideline for electronic claims Requesting corrections claim logic issue EDI: ANSI to CMS 1500 Crosswalk knowledge-viewing electronically submitted claim information, loops and segments
- Follow up with insurance company's to secure provider enrollment approval through provider number (PIN) assignment. Enter approval information into CredStream so billing company's can be notified to release claims.
- Monitor carrier websites for forms revision and update master provider enrollment packets as needed.
- Requesting corrections/ updates on taxonomy codes, provider billing group NPI. Tax id numbers per state Medicaid
- Researched and resolved invoices routed to the Specialist Views including EscalatedViews, CE Views Correspondence ,CPE Vies, Rejection Views.
Sr. Claims Analyst/Team Leader
Dell Insurance - Dale, TX
Dallas, TX
06.2008 - 12.2013
- Determine claim processing protocols and apply the correct policies contracted Fee Schedule to the claim
- Commercial COB, Medicare Medicaid when applicable Received, sorted, batched, scanned and verified all incoming claims Managed claims adjudication and case negotiation process on Amisys System
- Synthesized data into comprehensive quarterly written reports for management regarding team performance
- Evaluated pending claims to identify and resolve problem blocking auto-adjudications
- Determine plan liability as well as diversion and recovery activities
- Ability to independently solve problems- using training and SOP & guidance on overages in deductibles/ coinsurance accumulators as needed during benefit period.
- Resolved overages in deductibles /coinsurance accumulators as needed during benefit periods
- Calculate payments based on member eligibility appropriate payment methodology Worked remotely with limited supervision, Team Lead for 10 Claim Specialist Demonstrated leadership by making improvement to work, process and training claims rep
- Motivated and encouraged team members to work efficiently Delegated daily task to team members to optimize productivity
- Demonstrated leadership by making improvements to work process,
- Documented production levels and material used to keep management informed.
- Organized and prioritized incoming work orders and optimized team workflow and resources to handle dynamic demands.
- Motivated and encouraged team members to communicate more openly and constructively with team members and supervisor.
- Delegated daily task to team members to optimize group productivity
- Monitored team progress and enforced deadlines.
- Fostered positive employee relationship through communication training and development coaching
- Collaborated with management team to implement new work procedures
Education
GED -
Bill J Priest
Dallas, TX05-1999
Psychiatric Assistant -
PCI Health Training Center
Skills
- Conflict Resolution
- Analytica and Critical Thinking
- Training
- Data Analysis
- Detailed Oriented
- Strong Leadership
- Adaptability
- Quality Standard Compliance
- Healthcare Knowledge, Medical Terminology
- Conflict Problem Resolution
- Critical Thinking
- Organization and Time Management
- HIPAA Compliance
- Stress Tolerance
- Investigative research
- HIPAA Compliance
- Stress Tolerance
- Operational Reporting
- Software - MHS,CPD,Citrix,My Pay,Share Point,Kronos,CRM, Emp Center,Nuance,Prime,Omni,Cenpas,Tool Chest,Microsoft( Word,Excel,Access, Power Point, IDX,Navigator,Amisys Tru Care, US Script, Micro-strategy, MACESS, Service Now, Emdeon, Xcelys, Availity, Emdeon, Know;edge Library, OnBase, Centricity,Diamond- Facets,WGS, Sales Force, Navinet, Sales Force,
Timeline
Business Analyst 2
Centene Corp - Aline Staffing
02.2023 - 05.2023
Processing Representative Annuities
New York Life Insurance Co
10.2022 - Current
Accounts Receivable Analyst
SCP Health - Dallas, TX
11.2018 - 10.2022
Provider Enrollment Specialist
SCP-Health - Dallas, TX
07.2015 - 11.2018
Sr. Claims Analyst/Team Leader
Dell Insurance - Dale, TX
06.2008 - 12.2013
GED -
Bill J Priest
Psychiatric Assistant -
PCI Health Training Center
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