David Horton
Manager of Cost Containment at QualCare Inc.- Claim this Profile
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Bio
Harvey Rosenthal
I worked with David in HIP Claims department when I was part of Claims Systems Managment. At the time, I was involved in system discrepancies and enhancements of the Claims processing system. David communicated any system discrepancies he identifed to me so that I can report them. In addition, he was eager to know about system enhancements and would not hesitate to ask questions. I found David to be very well spoken, communicating in a succinct manner. In addition, he is pleasant, very knowlegeable about Claims processing and a team player. I highly recommend David.
Nicholas Kambolis
David and I worked on several projects at EmblemHealth. I found his dedication to completing the task and his attention to quality of the work product excellent. He completely researches all aspects of a project before acting. I also found that David a pleasure to work with and an excellent team player.
Harvey Rosenthal
I worked with David in HIP Claims department when I was part of Claims Systems Managment. At the time, I was involved in system discrepancies and enhancements of the Claims processing system. David communicated any system discrepancies he identifed to me so that I can report them. In addition, he was eager to know about system enhancements and would not hesitate to ask questions. I found David to be very well spoken, communicating in a succinct manner. In addition, he is pleasant, very knowlegeable about Claims processing and a team player. I highly recommend David.
Nicholas Kambolis
David and I worked on several projects at EmblemHealth. I found his dedication to completing the task and his attention to quality of the work product excellent. He completely researches all aspects of a project before acting. I also found that David a pleasure to work with and an excellent team player.
Harvey Rosenthal
I worked with David in HIP Claims department when I was part of Claims Systems Managment. At the time, I was involved in system discrepancies and enhancements of the Claims processing system. David communicated any system discrepancies he identifed to me so that I can report them. In addition, he was eager to know about system enhancements and would not hesitate to ask questions. I found David to be very well spoken, communicating in a succinct manner. In addition, he is pleasant, very knowlegeable about Claims processing and a team player. I highly recommend David.
Nicholas Kambolis
David and I worked on several projects at EmblemHealth. I found his dedication to completing the task and his attention to quality of the work product excellent. He completely researches all aspects of a project before acting. I also found that David a pleasure to work with and an excellent team player.
Harvey Rosenthal
I worked with David in HIP Claims department when I was part of Claims Systems Managment. At the time, I was involved in system discrepancies and enhancements of the Claims processing system. David communicated any system discrepancies he identifed to me so that I can report them. In addition, he was eager to know about system enhancements and would not hesitate to ask questions. I found David to be very well spoken, communicating in a succinct manner. In addition, he is pleasant, very knowlegeable about Claims processing and a team player. I highly recommend David.
Nicholas Kambolis
David and I worked on several projects at EmblemHealth. I found his dedication to completing the task and his attention to quality of the work product excellent. He completely researches all aspects of a project before acting. I also found that David a pleasure to work with and an excellent team player.
Credentials
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Six Sigma Black Belt
ExpertRating Inc.Oct, 2017- Nov, 2024
Experience
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QualCare Inc.
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United States
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Hospitals and Health Care
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100 - 200 Employee
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Manager of Cost Containment
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Oct 2017 - Present
• Manage overall negotiations of 5 Negotiators and 4 Coordinators on the review of Medical and Hospital claims agreements. • Serve as SME for high dollar cost containment dollar savings • Managed project development plan for SOP review and update. • Interprets Workers' Disability Compensation Act to Negotiators when requesting discounts and sending Letter of Agreements (LOA). • Responds to questions, telephone calls, and letters regarding the company's cost containment program, utilization review decisions, and reductions. • Analyzing claims history for primary and secondary diagnosis in order to ensure correct listing of chronic conditions concerning payment reimbursement and recoupment. • Establishes channels of communication with providers to familiarize them with CIGNA guidelines. • Trains and assists claims staff on quality health care cost containment and utilization reviews procedures for preoperative and postoperative discount negotiations. • Work with vendors for difficult negotiations. • Show less
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UnitedHealth Group
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Hospitals and Health Care
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700 & Above Employee
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Manager Northeast Region Community & State
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Feb 2013 - Jul 2017
Manages day to day operations, resource to staff, maintaines extensive knowledge of regulations for Northeast Region - NY, NJ, CT, DE, PA and MD, ensures the compliance of the department including contracts procedure amounts with state and federal rules, regulations and guideline regarding notices of action, attend Fair Hearings for Medicaid members. • Serve as a catalyst for implementing an appropriate risk assessment. • Developed process for clinical claims recoupment and reimbursement for CMS Medicare/Medicaid secondary payer and commercial insurance requests. • Arranging claims review for hierarchical diagnosis and DRG payment review using ICD9/ICD10 codes review. • Analyzing claims history for primary and secondary diagnosis in order to ensure correct listing of chronic conditions concerning payment reimbursement and recoupment. • Implement claims configuration and modifications • Performs internal Quality Control reviews on processes and activities while developing recommendation for improvement. • Manages several process changes including HIPAA rules when applies to faxes and email letter mailing. • Hiring new staff to ensure adequate departmental resources to handle increased member inquires based upon the Obama Care, Medicaid Affordable Care Act (ACA) Section 1321(c)(1)(B), beginning January 1, 2014, states must provide consumers who do not have employer-provided insurance the ability to purchase insurance through an Affordable Insurance Exchange. Show less
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EmblemHealth
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United States
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Insurance
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700 & Above Employee
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Lead Revenue Management Specialist
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Feb 2012 - Feb 2013
• Reviews and implements all Provider, Ancillary and Facility rate agreements in the Medical Claims System.• Understands and adheres to the objectives, work process, and desired outcomes of work flows and projects related to medical and hospital fee schedules, claims, provider contracts, and all departmental audits and medical policies.• Responsible for implementing all CPT and ICD updates. Assist in the preparation and review of business specifications and PPM's for system enhancements and modifications needed to support contractual agreements. • Complete manual configuration of all Provider/Facility/Ancillary rate agreements in the Medical Claims System, Medical Mass Adjustment review and validation of all reports generated, gathering of appropriate approvals from senior management, execution of the re-adjudication, and notification to all affected departments.• Develops test plans and completes file and data validation for rate updates and file design program changes instituted by IT. Performs post implementation validation of all changes moved into the production environment.• Initiates additions, changes, or deletions of records contained in references file housed in the Medical Claims System.• Analyzes data contained in all associated claims processing file for validity, recommending and/or initiating corrections or modifications. Show less
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Quality Assurance Specialist
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Feb 2008 - Feb 2012
Reviewed all claims from a quality assurance perspective, monitored contracts, improved processes, conducted audits for all departments and managed various audits and Medicare compliance projects.• Created process outlines and determined the quality of process outputs by identifying defects, minimizing variability and exploring best practice and process improvement opportunities• Performed UAT testing on ESAWS and Seibel8 defect test scripts• Audited broker and selling agent contracts info with Account Services area to ensure correct plan benefit (HMO, PPO, EPO and POS) uploaded.• Pulled UB04, UB92, HCFA1500 claim forms to audit for ICD9, CPT4, HCPCS and Hospital DRG coding errors.• Ensure complete adherence to National Committee for Quality Assurance (NCQA) Health Plan Accreditation and Health Insurance Portability and Accountability Act (HIPAA) guidelines. S. Gallagher-Reid • Provided assistance in determining and evaluating root causes of trends observed from audit findings to correct problem areas to increase productivity and efficient.• Guaranteed compliance with departmental standard procedures by performing secondary level review on auditors.• Collected and analyzed claims data retrieved via data mining from claims warehouse to ascertain whether trends in provider claims payment such as Capitation and Fee for Service payment schedules were correct. Show less
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Third Party Recovery Specialist
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Feb 1998 - Feb 2008
Initiated the processing of priority and non-priority claims. Conducted investigation and adjudication of professional and hospital claims related to Medicare, No-Fault, and Workmen Compensation in compliance with regulatory guidelines. Worked collaboratively with internal departments and external vendors to coordinate focused group discussions.Acquired feedback, coached, and conducted on-the-job training to claims examiners and management staff regarding appropriate policies and procedures to adjudicate claims. Facilitated payment recovery on overpayments associated with secondary payer audits that exceeded the terms and conditions outlined in the contract.Ensure complete adherence to National Committee for Quality Assurance (NCQA) Health Plan Accreditation and Health Insurance Portability and Accountability Act (HIPAA) guidelines.Evaluate workflow quality and efficiency by effectively implementing improved HEDIS statistical performance measures Show less
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Prudential Property & Casualty (PRUPAC)
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Holmdel, New Jersey
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Assistant Underwriter
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Mar 1996 - Feb 1998
Analyze the data in the insurance application forms and determine the credit worthiness of the applicant in complex and intriguing cases. Consult and work with the state insurance laws and regulations and/or legislation. Refer to our head office in the underwriting department for any clarifications or changes in the insurance underwriting coinciding with company policy. Facilitating the training of the junior underwriters about the insurance underwriting policies and strategies to improve product quality on our team. Design and shape the underwriting manuals for the other junior team members. Evaluate the financial position of the company and attend all audit meetings. Plan, depict, and format the training programs for the insurance agents while introducing the new plans or modifications made in an existing and presiding policy. Manage the queries or lawsuits filed against any insurance claims. Show less
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Education
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2010 - 2012
Florida Institute of Technology
Bachelor's degree, Business Systems -
1990 - 1993
Upsala College
Bachelor of Business Administration - BBA, Business Administration and Management, General
Community
