David Horton
Irvington,NJ
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.
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, NJ
Raritan, NJ
01.2021 - 01.2023
- 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 Supervisor
Qualcare / Cigna Healthcare Insurance LLC, Piscataway, NJ
Piscataway, NJ
01.2017 - 01.2021
- 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, NY
New York, NY
01.2012 - 01.2017
- 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
01.2007 - 01.2012
- 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-f-for-Service) using data mining tools.Performed secondary audits to ensure adherence to departmental procedures.
Claim Processor / Third Party Recovery Claims Specialist
01.1999 - 01.2007
- 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 - undefined
Malcolm X Shabazz High School
06.1985
Skills
- Service Operations
- Claims Processing
- Utilization Management
- Pre – Cert and Authorization
- Project Management
- Strategic Planning & Analyst 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 (advanced formulas, pivot tables), Access, Seibel Systems, SAP, RMUS
- Process & Quality Management
- Model N, Maxis Care, McKesson
- Documentation & Testing Environments
- Medical Claims System (UB04, HCFA1500), Defect Management Systems, Test Case Traceability Protocols
- Compliance & Coding Standards
Certification
- ITU Medical Billing & Coding Certificate
- ExpertRating Global Certification
- Sigma Black Belt Certificate (Oct 2018)
Timeline
Chargebacks & Memberships Analyst (Business Analyst 4)
Insight Global / IQVIA – Sanofi Pharmaceutical
01.2024 - Current
Medicaid Rebates Analyst
Mason Grey Contract / Johnson & Johnson – Raritan, NJ
01.2021 - 01.2023
Medical Cost Containment Supervisor
Qualcare / Cigna Healthcare Insurance LLC, Piscataway, NJ
01.2017 - 01.2021
Lead Revenue & Vendor Management Specialist
EmblemHealth Insurance, HIP & GHI — New York, NY
01.2012 - 01.2017
Senior Quality Assurance Specialist
01.2007 - 01.2012
Claim Processor / Third Party Recovery Claims Specialist
01.1999 - 01.2007
Bachelor's Degree Candidate - Business Systems
Florida Institute of Technology
High School Diploma - undefined
Malcolm X Shabazz High School