David E. Umpierre Rodríguez, CPC, CPMA

Experience

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  Medical Card System Inc.

  Feb 2011 - Mar 2012

  Call Center Supervisor

  Responsible for supervising directly twenty five (25) Customer Service Representatives and, indirectly, up to a hundred (100) Customer Service Representatives, promoting a timely response for every inbound call in the Call Center's various lines of business (Classicare, Commercial, MI Salud and Telemarketing) and meet the service indicators established by the department, while meeting, fully and consistently, the standards, policies and procedures of the Company, in conjunction with local and federal laws applicable to the medical insurance industry, business and employment practices.Successfully monitor personnel to ensure they met the different regulatory requirements and the service and quality indicators established, such as productivity, schedule fulfillment, quality of service and documentation, in order to discuss,present areas of opportunity to improve and/or development plans for the employees, according to the results obtained, as well as identify trends, prepare and plan the agenda for training employees as necessary. Show less

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  Humana

  Mar 2012 - Mar 2015

  Supervised and served as support and guidance to two (2) teams consisting of six (6) Prepay Audit Analysts and eight (8) Subrogation Specialists, managing high standards for claim cost management by pledging payment integrity through thorough audits of contracting payment provision loads and prompt management of subrogation related correspondence and check refunds.Successfully collaborated with analysts and consultants locally, with our corporate partners in the United States and with our external vendors, with defining expectations, guidelines, metrics, outcomes, processes and trends for both teams, leading meetings with my associates and collaborators to ensure optimum performance and results.Selected to participate of the Perfect Experience Summit of 2014 within the Humana Claims Cost Management organization to take charge of cascading the experience to the organization in Puerto Rico.Participated in the 2014 Perfect Service Experience in the Disney Institute after demonstrating my desire to create ultimate experiences, with both, internal and external customers, leading by example, analyzing projections and results proactively, and with a huge craving to grow professionally, engaging my team, lead or not by me, in a collaborative development. Show less Supervised and served as support and inspiration to eight (8) Provider Network & Contracting Representatives, providing guidance directly to providers and/or consumers while maintaining high standards for quality and an exceptional provider and consumer experience, actively coaching the team on bringing quick resolution to a variety of provider and/or consumer needs, while prioritizing network needs both quantitatively and qualitatively, negotiating favorable contracts and ensuring a competitive network.Successfully instituted different metrics to evaluate associate’s performance and the team’s overall monthly, quarterly, annual and project’s performance, serving, also, to identify trends and present results for different audiences, including internal and external customers.Selected to participate of the Perfect Service Summit of 2012 within the Humana Military organization to take charge of cascading the experience to everyone in the Provider's organization in Puerto Rico. Show less

  • Claims Cost Management Frontline Leader

    Oct 2013 - Mar 2015

  • Provider Network & Contracting Frontline Leader

    Mar 2012 - Oct 2013
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  Molina Healthcare

  Mar 2015 - Feb 2021

  Support the provider network contracting management through financial and network pricing modeling, analysis and reporting for well-informed negotiations, anticipating possible barriers and issues, to reach the best terms in good faith with sustainability.Lead the development, deployment and maintenance of contract modeling processes and applications.Support leadership in identifying unit cost savings, network optimization opportunities and financial performance improvement, performing complex conceptual and contractual analyses, using network reimbursement methodologies that adapt and respond to ASES and CMS guidelines and regulations.Lead different cost savings and unit cost pricing initiatives for new contracts, contracts renewals and amendments, seizing opportunities to optimize contracting models, coding, pricing and cost management. Show less Responsible for strategically coordinating and managing the cost savings (pre-payment) and claims recovery (post-payment) functions and processes for the Puerto Rico market, leading Certified Professional Coders and Registered Nurses, amongst other professionals, for the Claims Recovery, Code Editing, Code Edits Disputes and Medical Claims Review teams.Successfully implemented, locally, the corporate cost savings and claims recovery operations for the Puerto Rico market, building strategic relationships with different health plan operations, with leadership in a corporate setting, outside the market.Facilitate meetings with Health Plan representatives to discuss ongoing activity and situations affecting providers’ payments, working and removing barriers, while providing assistance to the Code Edits team with information exchange on appeals and critical matters resulting from code edit application on claims.Understand State requirements related to all cost savings and recovery processes and initiatives to ensure compliance, contractual, legal and regulatory fulfillment. Show less

  • Network Pricing & Analytics Manager

    Feb 2018 - Feb 2021

  • Cost Savings & Recovery Manager

    Mar 2015 - Feb 2018
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  Plan de Salud Menonita

  Mar 2021 - Jun 2023

  Payment Integrity & Cost Savings Director

  Responsible to ensure that all payment processes, policies, and transactions follow all federal and state rules and regulations, by reviewing and supervising payment behavior to facilities and providers. Identify the correct billing and payment of services rendered, waste of funds, and abuse of coding and billing rules, among others. Develop policies and procedures to meet industry and agencies standards. Implement and manage cost containment programs, identification of risks and vulnerabilities in payment to providers that include, among others: the integrity of the pre-payment and post-payment processes. Advise the company on compliance with law and regulations through detailed reports on risk exposures. Manage effective action plans in response to audit discoveries in collaboration with the Special Investigation Unit (SIU), ensuring compliance with state and federal regulations. Proactively audit prepayment and post-payment processes and practices to identify irregular behavior in provider billing. Audits the quality of the adjudication of claims and the configuration of benefits, contracts, and fee schedules, based on state and federal regulations, and the standards of expert professional associations, among others. Show less

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  UnIQ Healthcare Solutions

  Jan 2023 - now

  CEO & Founder

  Consulting, education, coding and data analytic solutions for medical providers, facilitating a better revenue cycle.

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  Molina Healthcare

  Jun 2023 - now

  Configuration | Implementation Quality Audit Lead Analyst

  Support the Configuration Department working on new implementations for the Medicaid line of business with claims tests that challenge the configuration, as well as executing quality audits to guarantee the best configuration and implementation possible.