CURLECIA HUDSON
RICHARDSON,TX
Summary
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. Adept 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.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Patient Access Analyst
SMITH RX
PLANO, TX
10.2024 - Current
- Acted as consultant to prescription benefit programs by interpreting regulations and policies.
- Assisted with applications for eligible members through drug manufacturers with their insurance benefits.
- Provided crisis intervention support for clients in emergency situations.
- Facilitated communication between providers, pharmacists, and members concerning medication coverage issues or questions.
- Collaborated with other departments to ensure timely resolution of claims payment issues.
- Researched, identified and resolved discrepancies between claims processing systems.
- Adhered to HIPAA regulations when handling confidential information related to patients' medical records.
- Analyzed member eligibility for prescription benefits in accordance with plan provisions.
- Reviewed and processed prescription benefit requests from medical providers, pharmacies and members.
- Assisted with training new staff on processes related to the management of prescription benefits.
- Provided guidance on resolving complex pharmacy benefit matters.
- Exceeded customer satisfaction by finding creative solutions to problems.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Conducted testing of software and systems to ensure quality and reliability.
Payment Processor II
DELUXE CORPORATION
Carrollton, Texas
08.2023 - Current
- 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
- Header batched items 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
- Assist with training when needed
Client Benefits Testing Analyst
CVS HEALTH
Irving, TX
11.2015 - 01.2023
- Plan benefits testing- formularies, utilization management, and clinical criteria for Caremark's premier commercial, Medicare Part D/Medicaid clients
- Construct customized MS Excel spreadsheets (test beds) for testing based client intent
- Executed macros to establish plan setups, add adjustments, and member creation
- Validate financial impact and claims adjudication based on client business specifications
- Verify claims validity in AS400/RxClaims
- Work in partnership with coding team to mediate plan inconsistencies
- Manage plan benefit lifecycle, defect management and case updates in Salesforce.com
- Utilize Visual Studio.net to compare formulary files for discrepancies
- Aided in developing team testing assigned based on business needs
Sr. Pharmacy Claims Business Analyst
OPTUM RX
Plano, TX
11.2012 - 11.2015
- SME for Medicare Part D Formulary Testing
- Developed initial set up of complex scenarios via MS Excel spreadsheets provided by the Clinical Department
- Customized data and manually transferred plan specific information to macros to be tested 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 results within RxClaim reporting discrepancies to clinical team for review, and follow up
Engagement Specialist
OPTUM HEALTH
Richardson, TX
10.2011 - 11.2012
- 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
DR. JEFFERY CATTORINI MD
Plano, TX
05.2011 - 09.2011
- 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
- Distribute patient's monthly statements
- Answer all inbound calls, and handle all third party requests regarding billing
- Adjust and post patient payments, determine payment plan options
- Collect delinquent funds from patients prior to scheduled appointments
- Process refund requests by insurance companies
- Prepare month end billing collection reports to the provider
Benefit Case Manager Liaison
CVS CAREMARK - THERMACOM
Richardson, TX
01.2010 - 04.2011
- Liaison for medical and prescription insurance coverage between the prescribing physician, patient and treatment provider
- Provide personalized billing options for physicians and patients served
- Rectify specific billing issues associated with the specialty medications, and health care coverage
- Identify the benefit option that results in lowest out-of-pocket cost to the patient
- Support physicians in completing and filing statements of medical necessity
- Expedite prior authorization for the treating provider
- Assist the prescribing physician by involving the patient in crafting second and third level appeals when prior authorization is initially denied
- Make recommendations to low income and Medicare D patients in regards to co-pay assistance programs
Customer Care Representative
CVS/CAREMARK
11.2007 - 01.2010
- Assist members, and clients via telephone regarding prescription benefits
- 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-pay's, 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 Appeals Specialist
BCBS OF TEXAS
Richardson, TX
12.2002 - 10.2007
- 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 inquiries, 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
Education
Medical Billing & Coding Certificate -
Practice Management Institute
05.2012
Richland College -
Richland College
Dallas01.2001
High School Diploma -
L.V. Berkner High School
Richardson01.1998
Skills
- Problem resolution ability
- Medical
- Project management
- Coding capability
- Self-motivated
- Extensive medical terminology
- Strong verbal communication
- Healthcare billing proficiency
- Data management
- Familiarity with disease management
- Process implementation
- Dedicated to process improvement
- KPI analysis
- Excel proficiency
- Decision-making
- Compliance analysis
- Team collaboration and leadership
- Information gathering
- Attention to detail
- Policy improvements
- Documentation and reporting
Certification
Medical Billing and Coding Certified
Timeline
Patient Access Analyst
SMITH RX
10.2024 - Current
Payment Processor II
DELUXE CORPORATION
08.2023 - Current
Client Benefits Testing Analyst
CVS HEALTH
11.2015 - 01.2023
Sr. Pharmacy Claims Business Analyst
OPTUM RX
11.2012 - 11.2015
Engagement Specialist
OPTUM HEALTH
10.2011 - 11.2012
Provider Collections and Claims Analyst
DR. JEFFERY CATTORINI MD
05.2011 - 09.2011
Benefit Case Manager Liaison
CVS CAREMARK - THERMACOM
01.2010 - 04.2011
Customer Care Representative
CVS/CAREMARK
11.2007 - 01.2010
Provider Inquiry Appeals Specialist
BCBS OF TEXAS
12.2002 - 10.2007
Medical Billing & Coding Certificate -
Practice Management Institute
Richland College -
Richland College
High School Diploma -
L.V. Berkner High School
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