ANTONIO PRUITT
St Louis,MO
Overview
12
12
years of professional experience
1
1
Certification
Work History
Licensed Property Claims Adjuster
Chubb Insurance
11.2021 - Current
- Clarify coverage of losses to policyholders and provide assistance in itemizing damages and finding alternative living arrangements.
- Review insurance policies to ascertain levels of coverage and determine whether claims receive approvals or denials.
- Upsell policyholders on recommended partnered contractors for mitigation and reconstruction services.
- Follow up on potentially fraudulent claims initiated by claims representatives.
- Handle claims related to water losses, wind/hail damage, mold, valuable articles, and additional living expenses (ALE).
- Develop and maintain working relationships with independent adjusters and contractors to assist in prompt claims handling.
- Direct claims negotiations within an allowable limit of $25,000.
- Adjust claims for commercial properties.
Appeals Specialist
Essence Healthcare Inc
09.2019 - 07.2020
- Prepared case files for Independent Review Entities, Medical Directors, and other levels of the appeals process.
- Conducted prior authorizations and price checks for formulary, non-formulary, and controlled substances medications under Medicare Part B and D.
- Managed appeals for skilled nursing, acute rehab, outpatient hospitals, durable medical equipment (DME) products, and dental offices for members under Medicare Part C post-service.
- Supported the internal and external audit processes.
Claims Grievances & Appeals Coordinator
Centene Corporation
12.2017 - 08.2019
- Worked directly with the quality of care, claims, member services, provider partnerships, legal services, pharmacy, appeals, medical transportation, and case management & compliance departments.
- Provided procedural clarifications and identified training needs for associates to management.
- Upsold members on participating in our transportation program to ensure they attended scheduled doctor appointments.
- Provided oversight for critical appeals processing tasks through the review and analysis of various reports.
- Analyzed captured data and provided business insights to appeals department leadership.
- Developed a new process for employee evaluation that resulted in marked performance improvements.
- Educated providers regarding policies and procedures related to referrals, claims submission, credentialing documentation, and website training.
- Led problem-solving and coordination efforts between various providers and members.
- Identified process and system gaps through in-depth research and assessment, and suggested methods for improvement.
- Developed an auditing program to address risks and evaluate regulatory requirements.
Program Coordinator
Centene Corporation
07.2015 - 12.2017
- Traveled to rural areas of Missouri to promote and educate members on available benefits.
- Completed health assessments with members to cover care gaps via outbound and inbound phone queues.
- Upsold members on participation in disease management programs.
- Contacted members with high emergency room (ER) utilization rates and educated them on the differences between ER and urgent care services, as well as the use of the 24-hour nurse line.
- Coordinated services with community-based organizations.
- Attended marketing and outreach meetings as directed to represent the health plan.
- Trained new employees.
- Trained new employees.
Health Program Representative
Aerotek
04.2014 - 04.2015
- Documented patient information obtained from interviews and conducted disease management surveys via telephone.
- Responsible for primary care, case management, and medication management.
- Encouraged members to participate in the disease management program.
- Evaluated patient care needs, prioritized treatment, and maintained patient flow.
- Partnered with a team of registered nurses to ensure the overall well-being of all patients.
Prior Authorization Representative
Express Scripts
11.2012 - 03.2014
- Provided information to clients, participants, pharmacists, and doctors regarding participants' pharmacy benefits, drug coverage, and accurate procedures for medication exceptions.
- Proactively addressed, researched, and resolved issues while maintaining accurate and complete documentation of all inquiries for continuous improvement.
Education
High School Diploma -
Missouri Western State University
Saint Joseph, MO05-2027
Skills
Microsoft Office Proficient
12 years experience in insurance
9 years of account management
Excellent oral and written communications
Sales/Upsell knowledge
Conflict Resolution
Strong time management skills
Takes initiative
Analytical Thinking
Process Improvement
Auditing
Inbound/Outbound calls experienced
Property Inspection
Claims Investigations
Authorize Payments
Certification
Licensed Property and Casualty Adjuster
Timeline
Licensed Property Claims Adjuster
Chubb Insurance
11.2021 - Current
Appeals Specialist
Essence Healthcare Inc
09.2019 - 07.2020
Claims Grievances & Appeals Coordinator
Centene Corporation
12.2017 - 08.2019
Program Coordinator
Centene Corporation
07.2015 - 12.2017
Health Program Representative
Aerotek
04.2014 - 04.2015
Prior Authorization Representative
Express Scripts
11.2012 - 03.2014
High School Diploma -
Missouri Western State University