GERARD A. PRATT
Owings Mills,Maryland
Summary
More than 25 years of administrative/supervisory experience within healthcare and military service. Results-driven, detailed-oriented with strong work ethics that optimizes resources to best serve and profit both external and internal partners. Demonstrated expertise in Appeals/Grievances, Managed Care, Compliance, Utilization Management, Claims Adjudication, Provider Relations, Customer Service and Team Leadership.
Overview
27
27
years of professional experience
Work History
Compliance Oversight Auditor
Health Net Federal Services, Inc.
01.2007 - 01.2018
- Provider Oversight Auditor has the responsibility of conducting all audits of Delegated provider and ancillary groups for the Region and be able to travel extensively
- Provide network management and able to work independently, organize work and audit schedules, including corrective actions and follow up, to ensure contract requirements are met and maintained
- Coordinate and perform on-site and web-based audits of Delegated groups
- Ability to control costs related to travel; ability to review provider files, group policies and procedures; ability to summarize findings and recommendations in reports for feedback to groups and for distribution to management and the Credentials Committee
- Credential and maintain Delegated provider's information
- Ability to run background checks; Knowledge of credentialing standards of all state and federal regulatory entities e.g
- URAC, NCQA, Joint Commission including researching requirements for various provider types; Monitor DHHS and Medical Board disciplinary actions, and follow up accordingly; Correspond with licensing board, certification agencies, training programs and medical groups to resolve any issues; and prepare file and overall status reports for monthly credentials committee
- Maintain communication with providers, groups, and HNFS management/internal partners
- Working with Provider Network Managers to establish new Delegated provider and ancillary groups including modifications with existing providers; assisting with maintaining overall contractual compliances
- Responsible for overall accuracy of the provider database, assuring that the information is current and presented internally and externally in a timely and professional manner
- Gather data, build/run reports, and send updates based data
- Reconcile discrepancies between group rosters and the database
- Identify problems and data trends and recommend appropriate follow up
- Review and revise departmental policies and procedures & desktop procedures related to Delegation credentialing
- Assist in the development of template letters and forms related Delegation and credentialing
- Assist in the training of co-workers and trainees on departmental systems and processes
- Coordinate and assist on internal projects and responsibilities under instruction of department managers and directors to include: Obtain follow up information as also requested by Credentialing Committee or Peer Review Teams
- Assist in special projects such a claims research, process improvement and database administration.
Provider Relations Representative
Health Net Federal Services, Inc.
01.2004 - 01.2007
- Provided network management including contract and credentialing request, on-site support, provider education and assistance to providers
- Assist providers and internal partners in investigating and resolving a wide variety of provider related issues
- Act as liaison between the plan and its providers responding to inquiries and complaints working to resolve provider issues
- Building and maintaining provider relationships
- Actively recruit providers as determined by analysis and network needs
- Perform and research provider set-up issues, database management and provider file maintenance
- Ensure accuracy of the provider directory
- Performing claims investigations and handling complex claims resolutions
- Maintain professional level of telephone and in-person etiquette.
Personal Assistant I/Claims Research Analyst
Sierra Military Health Services Inc.
01.2003 - 01.2004
- Assist beneficiaries, providers, and internal partners in investigating and resolving a wide variety of healthcare related issues ensuring the highest possible customer satisfaction
- Responsibilities included processing and resolution of a variety of medical and skilled nursing facility claims
- Demonstrated the ability to manage multiple tasks simultaneously in highly pressures situations and consistently meeting tight deadlines
- Answered incoming Tricare/Medicare calls regarding benefits, claims, eligibility and other complex issues
- Reviewed and investigated claim problems and coordinate activities with Sierra Claims Management Department and Tricare Finance and Operations areas
- Researched and reviewed recoupment and refund issues to ensure correct posting of adjustments
- Met departmental production standards and quality audits maintaining a high accuracy rate
- Acted as a direct liaison between beneficiaries, providers, and claims/medical management to resolve complex skilled nursing facility issues utilizing Medicare and Tricare guidelines.
Appeals-Grievance Coordinator/ Senior Customer Satisfaction Representative
CIGNA HealthCare Mid-Atlantic, Inc.
01.2000 - 01.2003
- Assist members, providers, and internal partners in investigating and resolving a wide variety of Healthcare related issues to ensure the highest possible member satisfaction
- Serve as a primary resource for CIGNA Healthcare Mid-Atlantic, Delaware and Pennsylvania plans regarding information on CIGNA Healthcare HMO products, appeal policies and procedures, claim inquiries, eligibility, HIPPA regulations
- Monitored weekly/monthly reports to ensure compliance within CIGNA policy and jurisdictional requirements
- Coordinated and facilitated appeal/grievance meetings with members, providers and Medical Executives to include preparation, presentation and resolution of all levels of appeals and grievances
- Collaborated with Medical Executives in the collection of medical documentation utilizing resources such as Milliman and Robertson Healthcare Management Guidelines, Technology Assessment and Utilization Management policies for medical review and insurance coverage determination
- Researched, investigated and appropriately documented written and verbal medical/pharmacy appeals within Corporate, NCQA, and state regulatory standards
- Researched and resolved all levels of administrative and medical necessity CIGNA Behavioral Health appeals as mandated by NCQA, state jurisdictions and utilization management policies maintaining strict confidentiality
- Reviewed and prepared appropriate cases for presentation to internal and external physician advisors for medical/psychiatric recommendation
- Provided oral and written resolution to internal partners and members/providers regarding the outcome for appeals, quality of care/service concerns
- Corresponded directly with employer groups, attorneys, contracted and delegated entities to insure members benefits are administered in accordance with policies
- Trained new associates on various Cigna Healthcare applications, state regulations, Utilization Management and NCQA compliance standards
- Achieved and exceeded unit standards on monthly file appeals and grievances
- Actively participated in Quality Management providing collaborative input and feedback regarding quality of care improvement, NCQA improvement and regulatory reporting
- Managed CIGNA Medicare for Seniors appeals through resolution utilizing Federal Medicare policies, Corporate, and regulatory guidelines.
Benefits Examiner
ERISA Designed System & Administration
01.1997 - 01.2000
- Responsibilities included processing and resolution of a variety of medical and dental claims
- Demonstrated the ability to manage multiple tasks simultaneously in highly pressures situations and consistently meet tight deadlines
- Obtained extensive knowledge of third party administrator products and policy guidelines, including stop-loss contracts and self-funded benefit plans to process claims effectively and efficiently.
Claims Examiner III/Customer Service Representative
Claims Administration Corporation
01.1991 - 01.1997
- Facilitate timely and accurate processing of medical/dental claims and adjustments
- Accurately processed and adjudicated a variety of medical/dental claims including handling complex entities e.g., PPO, High Dollar, Medicare & Medicaid reimbursement, Foreign, COB and Prescription drugs according to plan benefits and negotiated contracts with providers and vendors
- Served as a direct contact between claims department, subscribers and providers to resolve issues.
Education
Did Not Graduate -
Morgan State University
Baltimore, MDCertified Army Instructor/Trainer -
Unites States Army Education System
Professional Job Development Courses
Skills
Audit Reporting
Compliance
Appeals-Grievances
Claims Adjudication
Customer Service
Military History
Maryland Army National Guard, Pikesville, MD, 01/01/1978, 12/31/1999, Artillery Platoon Sergeant/Trainer (Retired), Assists platoon leader in the planning, preparation, and execution of collective training activities of the platoon. Conduct battery/platoon reconnaissance, selection, occupation, and defense of position areas. Supervise and train Artillery personnel engaged in firing battery operations and maintenance of all assigned platoon equipment. Conduct and verifies safe operations before and during firing of Artillery equipment. Supervises battalion ammunition operations. Reviews, consolidates, and prepares technical, personnel, and administrative reports covering Artillery operations. Directly responsible for the morale, welfare, discipline, and accountability of personnel. Prepare and conduct military personnel performance evaluations.
Timeline
Compliance Oversight Auditor
Health Net Federal Services, Inc.
01.2007 - 01.2018
Provider Relations Representative
Health Net Federal Services, Inc.
01.2004 - 01.2007
Personal Assistant I/Claims Research Analyst
Sierra Military Health Services Inc.
01.2003 - 01.2004
Appeals-Grievance Coordinator/ Senior Customer Satisfaction Representative
CIGNA HealthCare Mid-Atlantic, Inc.
01.2000 - 01.2003
Benefits Examiner
ERISA Designed System & Administration
01.1997 - 01.2000
Claims Examiner III/Customer Service Representative
Claims Administration Corporation
01.1991 - 01.1997
Did Not Graduate -
Morgan State University
Certified Army Instructor/Trainer -
Unites States Army Education System
Professional Job Development Courses