Summary
Overview
Work History
Education
Skills
References
Certification
Timeline
Generic
Pragna Adule

Pragna Adule

Conyers,GA

Summary

Seasoned Certified Professional Coder, Market Access, and Reimbursement Specialist. Practice management professional with copious healthcare experience, which includes over 15 years of Buy and Bill, Internal Medicine, Behavioral health, Immunology,Neuroscience, Ophthalmology, Oncology, OB/GYN and multi-specialty practices. With intensive experience in recruitment/ human resources policies and procedures, accounts payable/ receivable, billing and insurance processing, project management, credentialing and contract negations, physician & staff scheduling, purchasing and marketing.

Overview

14
14
years of professional experience
1
1
Certification

Work History

Field Access Specialist

AbbVie Pharmaceuticals
09.2021 - Current
  • Cover extensive geography – GA, AL & FL
  • Review comprehensive insurance verifications for specialty therapies for the full range of insurance plans
  • Assist provider and office staff in resolving complex reimbursement issues that may create barriers to access for patients
  • Provide proactive education to new and experienced office staff about patient support programs i.e
  • Copay assistance and patient assistance
  • Customize on site visits to meet the needs of accounts
  • Provide expertise on payer trends impacting patient access to therapies
  • Educate provider offices on local and regional payer issues, coding changes, and appropriate claims submission processes
  • Communicate with specialty pharmacies to update office on prescription status
  • Provide thorough understanding of the payer policy processes, published criteria and documentation for coverage, coding, prior authorization, and appeal processes.

Associate Director, Team Lead

XCENDA – J&J
08.2017 - 09.2021
  • Manage a team of 10 Field Reimbursement Managers
  • Support FRM in communicating payer policy updates and system changes that impacts access
  • Partner with internal and external stakeholders to identify, anticipate and address patient and practice reimbursement issues
  • Review market access and business plans and objectives for facilities that are capable of buy/bill products
  • Establishing relationships within a practice by working closely with them to help remove access barriers to specialty products for their patients
  • Provide live one-on-one support with FRM to address questions about coverage requirements
  • Assist provider offices in supporting the prescriber decision through to access with supporting the entire reimbursement journey through payer prior authorization to appeals/denials
  • Educating provider offices on local and regional payer issues, coding changes, and appropriate claims submission processes
  • Liaising with reimbursement hotlines regarding alternative funding/financial assistance programs
  • Assisting with determining coverage and access options available for a specific medication or procedure
  • Provide information on relevant access topics related to client’s product
  • Develop and execute geographical strategic and tactical plans to meet customer and business needs.

Senior Manager (contract assignment)

RPA Billing and Consulting Services
01.2015 - 07.2017
  • Lead Project Manager – Consulting for 2 practices
  • Practice startup - Implementing multi-specialty and Internal Medicine physician groups
  • Functionality involved, Credentialing Providers and on-boarding Medical Staff, Payroll, Benefits and Compensation
  • Recruitment, Training, Development of practice employee handbook and Employee Relations
  • Assisted in submissions grant proposals for NIH, HHMI and NAC
  • Assessing physician practice workforce and implementing techniques to increase productivity
  • Providing physician practice operations of subject matters specialization in clients’ engagements related to improving the efficiency of physician practice organization, as well as identifying strategic opportunities for growth of the practice
  • Developing, writing, presenting and facilitating discussions on strategy to practice owners/physician and management levels
  • Building and maintaining networks of client relationships
  • Partnered with Practice accountant and Lead Physician in developing strategic, operating and financial plans to support the practice mission
  • Managing resource requirements, project workflows, budgets, billing and collections
  • Supervised team and effectively communicating with clinicians to build an atmosphere of trust and solicit active participation in initiatives
  • Coaching staff including providing timely meaningful written and verbal feedback
  • Assessment of physician practice operating model, including strategy, capabilities, governance model, and compensation plan design
  • Using data analytics to identify opportunities and solutions; and Engaging clinicians in driving sustainable cultural and organizational change.

Physician Practice Operations Manager

ST. LUKES HOSPITAL AND HEALTH NETWORK
11.2010 - 12.2014
  • Manage clinic supervisors and provide direction regarding meaningful use and other operational goals of the practice and network
  • Serve as primary contact for the practices, and liaison between, physicians, patients, staff and technicians to facilitate proper lines of communication and expedient problem resolutions
  • Facilitated projects which included EMR implementation, upgrades and changes to department site at the main hospital campus, including the development of a Child-Friendly Behavior Health Treatment program, and installation of 5 separate machine upgrades across both the hospital site and the offsite location
  • Manage and process bi-weekly payroll for salaried and hourly employees using ADP
  • Perform credentialing responsibilities in an expeditious manner to bring on new physicians and allied practitioners
  • Maintain current status with insurance agencies and report concerns about the practice liability with credentials issues
  • Assisted in proposal and submissions of grants for clinic research and trials
  • Reorganization of the clinical support administrative structure and workflow of the department, resulting in increased scheduling efficiencies and access to the department for outside referrals, thus increasing patient, attending physician and referring physician satisfaction
  • Effectively negotiate contracts and obtain renewals with current contracts to assure that we are compliant with health plan and State standards
  • Ensure that all policies and procedures of network standards are effectively communicated to and implemented by all staff.

Education

Master of Science -

Rutgers University

Skills

  • Knowledge of NCQA, insurance contract negotiations, credentialing standards and delegated credentialing, CAQH, PECOS, HEDIS, JCAHO, MQSA, HIPAA, ACR, STARS, CMS, Medicare, Medicaid and commercial payors
  • Experienced with third party billing, Commercial and Government services billing (Medicaid, SSI, etc)
  • Experienced with EMR implementation; Systems include Eclinical Works, IDX, Medical Manager, WEB MD, Eagle, ADS, Nextgen, Salesforce, Valet, Irep, Citrix, Epic, Soarian, Allscripts and ATHENA

References

REFERENCES AVAILABLE UPON REQUEST

Certification

CPC

Timeline

Field Access Specialist

AbbVie Pharmaceuticals
09.2021 - Current

Associate Director, Team Lead

XCENDA – J&J
08.2017 - 09.2021

Senior Manager (contract assignment)

RPA Billing and Consulting Services
01.2015 - 07.2017

Physician Practice Operations Manager

ST. LUKES HOSPITAL AND HEALTH NETWORK
11.2010 - 12.2014

Master of Science -

Rutgers University

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