CURLECIA HUDSON
SmithRx
Richardson,TX
1
Certification
28
years of professional experience
Insightful and dedicated healthcare professional with 15 years of experience in the Medical and PBM industry, demonstrating expertise in customer service and payment processing. Proficient in medical coding, billing, appeals, and claims testing adjudication, with a strong focus on benefits testing and issue resolution. Experienced at navigating Medicare/Medicaid regulations and conducting health plan financial analysis to drive operational efficiency. Aiming to leverage extensive knowledge to enhance organizational performance in a dynamic healthcare setting
Work History
Patient Access Analyst
2 Years- Consulted on prescription benefit programs, interpreting regulations and policies to ensure compliance and clarity for stakeholders. Analyze member eligibility for prescription benefits per plan provisions. Review and process prescription benefit requests from providers, pharmacies, and members. Facilitated communication among providers, pharmacists, and members to clarify medication coverage and resolve inquiries. Research and resolve discrepancies in claims processing systems. Provide crisis intervention support for clients in emergency situations. Assisted in training new hires on processes related to prescription benefits management to enhance team knowledge and service quality. Adhere to HIPAA regulations while handling confidential patient information
- Analyzed data trends to support decision-making processes and enhance operational efficiency.
- Developed and maintained dashboards for real-time performance tracking and reporting.
- Collaborated with cross-functional teams to identify process improvements and streamline workflows.
Payment Processor II
1 Year 2 Months- Open payments and correspondence from clients and customers, extract transactions, batch checks, invoices, and coupons according to client instructions Perform complex transactions, sorting and decision-making per client specifications Execute minor adjustments and minor repairs to job related equipment Perform quality reviews on outgoing items including HIPAA clients and prepare outgoing packages for low/medium complexity customers Prepare daily reconciliation and billing reports Process work accurately and maintain performance output in accordance with department and client standards Pull rejected transactions from all processing areas using reports and processing audit trails with general knowledge of operations Perform basic level transaction sorting and decision-making Executed header batching of items with control documents for processing accuracy. with control documents and processing header Processing medium to high complexity client sorting and transaction decisioning Complexity is defined by client processing instructions Process work accurately and maintain performance output in accordance with department standards Facilitated training for team members on payment processes.
- Verified customer account information to ensure accuracy before processing payments.
- Generated detailed reports of payment activity to support management decision-making.
- Facilitated collaboration with other departments to enhance communication regarding payment processes. within the organization to ensure proper communication regarding payment processes.
Client Benefits Testing Specialist
8 Years 2 Months- Plan benefits testing- formularies, utilization management, and clinical criteria for Caremark's premier commercial, Medicare Part D/Medicaid clients.
- Constructed customized MS Excel spreadsheets (test beds) to align testing with client intent.
- Verified claims validity in AS400/RxClaim.
- Managing plan benefit lifecycle, defect management and case updates in Salesforce.com.
- Constructed customized MS Excel spreadsheets (test beds) for testing based client intent.
- Worked in partnership with the coding team to mediate plan inconsistencies.
- Utilizing Visual Studio.net to compare formulary files for discrepancies.
- Worked in partnership with coding team to mediate plan inconsistencies.
- Engage to creatively and appropriately find solutions to clients needs
- Developed team testing reference material and documentation, uploading documents on SharePoint.
- Completed various tasks to support team objectives.
Sr. Pharmacy Claims Business Analyst
3 Years 1 Month- Served as a subject matter expert for Medicare Part D formulary testing.
- Developing initial setup of complex scenarios via MS Excel spreadsheets provided by the Clinical Department.
- Collaborate with internal teams for client issue resolution
- Customized and transferred plan-specific data to macros for testing in AS400/RxClaim system.
- Analyzed and validated testing results to ensure adjudication process based on client business requirements and pay schedule specifications.
- Validation entails updates to formulary and non-formulary medications, tiering justifications, prior authorization, copay schedules, unbreakable logic packaging, age edits and quantity limits, generic bypass, step therapy, etc.
- Finalized and audited RxClaim results, addressing discrepancies for clinical review and follow-up.
Engagement Specialist
1 Year 2 Months- Telephonic support for providers and members.
- Actively engaging and communicating with potential enrollees, via outbound calls regarding disease management programs.
- Troubleshooting consumer program inquiries, and needs.
- Authenticate ICD-9 and CPT coding by means of the notification wizard for consumer referrals and vendors (internal and external).
- Update provider's status and determine if notification is essential.
- Providing superior customer service to both providers and enrollees.
- Consistently meeting established productivity, schedule adherence, and quality standards based on organizational guidelines.
Provider Collections and Claims Analyst
4 Months- Maintained and supported Provider's AR (Aging Report) on a daily basis.
- Submitted all electronic and paper claims for provider (office visits and surgery claims).
- Examine and make necessary adjustments on all rejected submissions.
- Research explanation of benefits and post insurance payments to patient's medical records.
- Forward appeals and corrected claims to insurance companies, follow up on all adjustments and appeals as needed.
- Adjust and post patient payments, determine payment plan options.
- Process refund requests by insurance companies.
- Prepare month end billing collection reports to the provider.
Benefit Case Manager / Liaison
1 Year 3 Months- Liaison for medical and prescription insurance coverage between the prescribing physician, patient and treatment provider.
- Delivered personalized billing options to enhance satisfaction for physicians and patients.
- Assist the prescribing physician by involving the patient in crafting second and third level appeals when prior authorization is initially denied.
- Rectify specific billing issues associated with the specialty medications, and health care coverage.
- Facilitated completion and filing of statements of medical necessity for physicians to ensure compliance and support patient care.
- Support physicians in completing and filing statements of medical necessity.
- Guided prescribing physicians in engaging patients to develop second and third level appeals for denied prior authorizations.
- Make recommendations to low income and Medicare D patients in regards to co-pay assistance programs.
Customer Care Representative
2 Years 2 Months- Assist members, and clients via telephone regarding prescription benefits.
- Responsible for troubleshooting escalated issues related to claims, eligibility, and general account maintenance
- Place mail order refills, and new prescription orders.
- Contact providers for new prescriptions, verification of eligibility and benefits for Caremark members.
- Manage and develop resolutions for escalated calls.
- Relay status of reimbursement claims, take payments and update payment methods.
- Effectively enroll participants in special programs.
- Offer discount program/products to decrease medication costs to the insured.
- Educate members about their benefit plan (co-pays, deductible, allowed benefits, etc).
- Provide price quotes and run test claims on patient's medication.
- Provide pharmacists with accurate input codes for processing retail claims, input overrides, prior authorizations, and place reshipment orders.
Provider Inquiry and Appeals Specialist
4 Years 10 Months- Researched written appeals and inquiries submitted by medical providers to ensure accurate and timely payment of medical claims.
- Compared provider's negotiated contracts, local pricing, state and federal mandated laws and member benefit policies.
- Initiated adjustments, voided and stripped claims billed in error, and conveyed the detailed resolution of the research via letter or by telephone to the medical providers.
- Assist members with self-submitted claims.
- Successfully communicated with internal departments, medical providers and other insurance companies on behalf of the members to resolve matters with rejected claims based on the subscriber's medical benefit policy.
- Decreased provider submitted inquires, by 100-300 per day while maintaining quality and productivity goals set by management.
- Obtained several awards for highest productivity, certificates for exceeding overtime goals and 100% quality award for 7 months.
Customer Relations Analyst
1 Year 10 Months- Researched and responded to customer's written correspondence, and internal escalations.
- Provided customers with immediate resolutions via telephone or mail.
- Enter applicable completed correspondence in database.
- Contact local telephone companies (ILECS) for PIC verification.
- Review TCSI codes on customer accounts.
- Issue credits and perform maintenance to customer accounts as needed.
- Maintain daily production as required by department standards.
- Perform root cause analysis of customer's issues and inform internal departments of inefficient processes.
Recovery Specialist
1 Year 2 Months- Provide inbound and outbound telephonic support.
- Recover lost revenue for clients.
- Assist customers in efforts to pay off debt due to our contracted clients, and help clean customer's credit report.
Education
Medical Billing & Coding Certificate
Skills
Problem resolution ability
Self-motivated
Extensive medical terminology
Strong verbal communication
Familiarity with disease management
Process implementation
Dedicated to process improvement
Excel proficiency
Decision-making Compliance analysis
Team collaboration and leadership
Information gathering
Attention to detail
Policy improvements
Documentation and reporting
Microsoft office
Analytical thinking
MS Excel
Time management
Project management
Critical thinking
Process improvements
Data research and validation
Deadline adherence
Certification
Medical Billing and Coding Certified
Contact
https://bold.pro/my/curlecia-hudson/352r
Timeline
Patient Access Analyst
SmithRx
10.2024 - CurrentRead More
Payment Processor II
Deluxe Corporation
08.2023 - 10.2024Read More
Client Benefits Testing Specialist
CVS CAREMARK (PBM)
10.2015 - 12.2023Read More
Sr. Pharmacy Claims Business Analyst
Optum RX (PMB-UHC Affliate)
10.2012 - 11.2015Read More
Engagement Specialist
Optum Health (PBM-UHC Affialate)
09.2011 - 11.2012Read More
Provider Collections and Claims Analyst
DR. JEFFERY CATTORINI MD
04.2011 - 08.2011Read More
Benefit Case Manager / Liaison
CVS CAREMARK - THERMACOM (PBM)
12.2009 - 03.2011Read More
Customer Care Representative
CVS Caremark (PBM)
10.2007 - 12.2009Read More
Provider Inquiry and Appeals Specialist
BLUE CROSS BLUE SHEILD OF TEXAS
10.2002 - 08.2007Read More
Customer Relations Analyst
EXCEL TELECOMMUNICATIONS
12.2000 - 10.2002Read More
Recovery Specialist
CMI
10.1998 - 12.1999Read More
L.V. Berkner High School
Read More
Richland College
Read More
Practice Management Institute
Medical Billing & Coding Certificate
Read More