David Horton
South Orange
Summary
Accomplished healthcare reimbursement analyst with 15+ years of experience specializing in Medicaid rebate adjudication, pharmaceutical chargebacks, and hospital/medical claims negotiation. Proven track record of leading teams to achieve $1M+ in monthly cost savings. Adept at managing complex contract setups, resolving dispute backlogs, and navigating Medicare/Medicaid compliance. Technically proficient in systems including QCare, Trizetto, and SAP. Known for driving process improvements and producing high-impact documentation in fast-paced payer and provider environments.
Results-driven Claims Processing Analyst with proven expertise in data accuracy and process optimization. Adept at managing customer records, resolving disputes, and leading cross-functional collaboration.
Detail-oriented Business Analyst with extensive experience in strategic planning and quality assurance. Demonstrated success in streamlining processes and enhancing data reliability, contributing to over $1M in savings and improved operational efficiency.
Dynamic professional skilled in effective communication and project management within the healthcare sector. Known for driving quality improvements and data accuracy, ready to leverage expertise to enhance operational outcomes.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Chargebacks & Memberships Analyst (Business Analyst 4)
Insight Global / IQVIA – Sanofi Pharmaceutical
01.2024 - Current
- Managed 20K+ customer records to ensure accuracy of DEA, HIN, 340B ID, and class of trade.
- Approved and processed changes to accounts utilizing Model N Flex platform, SAP and RMUS;
- Conducted class of trade research and updates via Model N Flex and Microsoft CoPilot.
- Maintained vendor relationships and oversaw end customer data workflows.
- Organized end customer data on behalf of specific manufacturer and hospital system.
- Cleaning, preparing and refining data to improve quality, accuracy and reliability in Model N and Excel.
- Cross-functional collaboration with Vaccines Membership, Pharma and Portal/ The HUB teams.
- Processed MDG Change Requests and other business priorities.
Medicaid Rebates Analyst
Mason Grey Contract / Johnson & Johnson
Raritan
01.2021 - 12.2023
- Resolved over $1M in current and past Medicaid rebate disputes, significantly reducing company backlog in Model N as well as revenue and contract management.
- Conducted in-depth financial analysis of pharmaceutical claims to identify incorrect invoice submissions.
- Collaborated with payment teams and state agencies to ensure timely resolution of dispute balances.
- Authored and revised process documentation and training instructions for the dispute resolution team.
- Led back-end audit processes to ensure compliance with state rebate programs and federal guidelines.
- Compared historical rebate data with 340B discount trends to uncover cost variances and improve adjudication accuracy.
Medical Cost Containment Manager
Qualcare / Cigna Healthcare Insurance LLC
Piscataway
01.2017 - 12.2021
- Directed a team of 9 in negotiating complex hospital and medical claims, achieving monthly savings of over $1M for clients.
- Led implementation of new healthcare provider contract load process, reducing system errors and improving reimbursement accuracy.
- Reviewed DME invoices and claims history to ensure accurate coding for chronic conditions and optimal pricing compliance.
- Streamlined contract setup and reimbursement procedures in alignment with CIGNA guidelines and CPT4 coding standards.
- Trained and mentored claims staff, boosting expertise in cost containment strategies and utilization reviews.
- Ensured regulatory compliance across Medicaid/Medicare claims and facilitated updates via Astellas Model N software.
Lead Revenue & Vendor Management Specialist
EmblemHealth Insurance, HIP & GHI
New York
01.2012 - 12.2017
- Led review and configuration of medical mass adjustments and manual A/R for provider contracts and facility rate agreements.
- Ensured compliance with fee schedules, claims workflows, departmental audits, and policy updates.
- Implemented annual CPT4, HCPCS, ICD-9/10, DRG, and contract uploads in claims system.
- Directed team of revenue analysts to execute coding updates and uploads.
- Authored business specifications and PPMs for system enhancements.
- Developed test plans and validated data integrity for rate updates.
- Oversaw re-adjudication processes and coordinated cross-departmental notifications.
Senior Quality Assurance Specialist
EmblemHealth Insurance, HIP & GHI
New York
01.2007 - 12.2012
- Audited 8 sample calls per agent across 35 reps monthly, assessing tone, verification, listening, and closure metrics.
- Conducted monthly 1:1 quality reviews and identified training needs based on QA scores.
- Led HEDIS audits during NCQA accreditation; ensured HIPAA and NCQA compliance.
- Reviewed claims and contracts for accuracy; improved QA processes across departments.
- Audited UB04, UB92, HCFA1500 forms for coding errors.
- Analyzed claims data trends (Capitation vs. Fee-for-Service) using data mining tools.
- Performed secondary audits to ensure adherence to departmental procedures.
Claim Processor / Third Party Recovery Claims Specialist
EmblemHealth Insurance, HIP & GHI
New York
01.1999 - 12.2007
- Adjudicated claims involving COB, overpayments, and underpayments across Medicare/Medicaid, No-Fault, and commercial plans.
- Processed hospital and medical claims for HMO, PPO, POS, MR, MD, and MS plans using QCare and MPFS tools.
- Resolved QCare edits (P10, P22) and calculated allowables via CMS guidelines.
- Created COB segments to prevent out-of-turn payments and streamline third-party recoupments.
- Trained new COB specialists on payer responsibility, EOB interpretation, and ESRD claim handling.
- Reviewed Medicare reimbursement requests for Parts A–D ensuring compliance and accuracy.
Education
Bachelor’s Degree Candidate - Business Systems
Florida Institute of Technology
High School Diploma -
Malcolm X Shabazz High School
Skills
- Service Operations
- Claims Processing
- Utilization Management
- Pre – Cert and Authorization
- Project Management
- Strategic Planning & Analysist
- Data Mining & Manipulation
- Hospital and Medical Contract Setup and Negotiations
- Technical Writing
- Documentation & Reporting
- Quality Assurance
- Team Building
- Proficient in Revitas
- Effective Communication
- Claims & Reimbursement Systems
- Model N Flex Platform
- QCare
- Facets
- Trizetto NetworX
- HIP GHI PRODHOSP
- CORPROD
- FASTRAK
- Uniflow
- Data Analysis & Reporting Tools
- Microsoft Excel
- Access
- Seibel Systems
- SAP
- RMUS
- Process & Quality Management
- Model N
- Maxis Care
- McKesson
- Documentation & Testing Environments
- Medical Claims System
- Defect Management Systems
- Test Case Traceability Protocols
- Compliance & Coding Standards
Certification
- ITU Medical Billing & Coding Certificate
- ExpertRating Global Certification
- Sigma Black Belt Certificate, 10/01/18
Technical Proficiencies
Model N Flex Platform, QCare, Facets, Trizetto NetworX, HIP GHI PRODHOSP, CORPROD, FASTRAK, Uniflow, Microsoft Excel (advanced formulas, pivot tables), Access, Seibel Systems, SAP, RMUS, Model N, Maxis Care, McKesson, Medical Claims System (UB04, HCFA1500), Defect Management Systems, Test Case Traceability Protocols
Timeline
Chargebacks & Memberships Analyst (Business Analyst 4)
Insight Global / IQVIA – Sanofi Pharmaceutical
01.2024 - Current
Medicaid Rebates Analyst
Mason Grey Contract / Johnson & Johnson
01.2021 - 12.2023
Medical Cost Containment Manager
Qualcare / Cigna Healthcare Insurance LLC
01.2017 - 12.2021
Lead Revenue & Vendor Management Specialist
EmblemHealth Insurance, HIP & GHI
01.2012 - 12.2017
Senior Quality Assurance Specialist
EmblemHealth Insurance, HIP & GHI
01.2007 - 12.2012
Claim Processor / Third Party Recovery Claims Specialist
EmblemHealth Insurance, HIP & GHI
01.1999 - 12.2007
Bachelor’s Degree Candidate - Business Systems
Florida Institute of Technology
High School Diploma -
Malcolm X Shabazz High School