KARENA WRATHER

• Spearheaded ERA/EFT enrollment initiatives for Medicaid and commercial payers, reducing payment delays and improving cash flow
• Led automated payment workflows, ensuring accurate billing data and seamless reimbursement across multiple payer systems
• Monitored and validated billing data integrity, identifying discrepancies and implementing corrective actions to enhance accuracy
• Coordinated with payers to obtain and reconcile EOBs, resolving issues promptly and minimizing claim denials
• Optimized ERA file linkage to provider groups and billing accounts, improving posting accuracy and system efficiency
• Executed detailed enrollment requests, ensuring compliance with payer requirements and facilitating timely onboarding

Revenue Cycle Claim Specialist

• Led full-cycle revenue cycle operations, including claims resolution and reimbursement analysis, to reduce revenue leakage
• Investigated and resolved high-dollar overpayment cases, performing root cause analysis and implementing preventive solutions
• Reviewed and validated payer contracts to identify discrepancies and ensure compliance with reimbursement terms
• Contributed to automation initiatives that improved adjudication timelines and operational accuracy
• Collaborated with billing, coding, and finance teams to strengthen workflows and ensure CPT coding accuracy
• Analyzed reimbursement trends and delivered actionable insights to support data-driven decision-making

• Supported complex annuity cases through in-depth analysis, tailored product design, and strategic proposal development aligned with client goals
• Performed financial analyses evaluating retirement planning, risk tolerance, and estate considerations
• Balanced high-volume workloads to enhance efficiency in case management and drive business development
• Conducted gap analyses to pinpoint inefficiencies and propose actionable process improvements
• Partnered with cross-functional teams to ensure accurate documentation and reporting using advanced financial systems

• Monitored and analyzed EDI transaction KPIs (837, 835, 270/271, 276/277, EFT) to identify trends and improve performance
• Oversaw EDI processing, including file validation, testing, and error resolution, ensuring timely claims submission
• Resolved integration issues (mapping errors, failed transactions, data discrepancies) in collaboration with internal and external partners
• Enhanced interface performance through proactive monitoring, minimizing delays and maximizing transaction success rates
• Tracked key metrics (latency, success rates, resolution time) to identify areas for continuous process improvement
• Ensured compliance with EDI standards, payer requirements, and regulatory guidelines
• Identified and resolved denial trends, improving reimbursement outcomes and A/R performance
• Developed job aids and documentation to standardize workflows and enhance team efficiency
• Administered payer enrollment and credentialing processes aligned with hospital privileging timelines

• Monitored and analyzed EDI transaction KPIs (837, 835, 270/271, 276/277, EFT), producing actionable reports to identify trends and optimize revenue cycle performance.
• Managed end-to-end EDI processing, including file loading, validation, testing, and error resolution, ensuring data integrity and uninterrupted claims flow.
• Investigated and resolved integration issues (mapping errors, failed transactions, data discrepancies) in collaboration with internal teams and external partners.
• Proactively monitored interface health using logs, alerts, and reconciliation reports, improving transaction success rates and reducing processing delays.
• Tracked performance metrics (success rates, latency, resolution time) to inform continuous process improvements and enhance operational efficiency.
• Ensured compliance with EDI standards, payer requirements, and regulatory guidelines, maintaining audit readiness and minimizing risk.
• Analyzed denials, rejections, and EOB data to identify trends and resolve claims issues, enhancing reimbursement outcomes and A/R performance.
• Conducted root cause analysis on billing discrepancies and denial trends, implementing preventive solutions to reduce recurrence.
• Prepared and submitted appeals (timely filing, medical necessity, underpayments), supporting consistent cash collection goals.

• Processed and submitted enrollment applications for Medicare, Medicaid, BCBS, and managed care plans aligned with privileging timelines and billing requirements
• Coordinated with payers and internal teams to resolve enrollment discrepancies, expediting approvals
• Maintained and tracked provider enrollment data in CredStream, ensuring timely claim release and PIN activation
• Served as primary contact for provider enrollment claim denials, resolving issues to maintain revenue integrity
• Prepared and submitted appeals, attestation letters, and documentation to reprocess claims and secure reimbursement
• Resolved claim rejections and enrollment-related billing issues using payer guidelines, including 837P ANSI Companion Guides and CMS-1500 standards
• Tracked and documented enrollment activity in Salesforce; generated Power BI reports to monitor status and performance

• Led a team of 10 Claims Specialists, delegating workloads and improving processing efficiency
• Coached and developed team members, resulting in improved accuracy and productivity in claims processing
• Negotiated and resolved claims using Amisys, ensuring compliance with plan guidelines while minimizing disputes
• Processed and adjudicated medical claims in accordance with contract terms and payer policies
• Applied coordination of benefits (COB) rules across commercial, Medicare, and Medicaid plans
• Directed claims intake operations, including batching, scanning, and verifying accuracy to enhance processing quality
• Resolved complex claims issues involving deductibles, coinsurance, and benefit limits
• Determined plan liability and supported recovery efforts to reduce financial risk
• Calculated payments based on eligibility and reimbursement methodologies