Mark S. Rivera

President @Managed Care Consulting, Inc

Newport Beach, CA, US

Specialty managed care consulting firm serving governmental, nonprofit, and for-profit healthcare entities with a national presence, focusing on provider network performance, compliance, and value-based reimbursements. • Negotiated complex capitation fee structures and specialty OB/Gyn and Dermatology sub-capitation contracts capturing millions in new revenue at AMSO. • Negotiated third-party payer contracts and recovered outstanding claims totaling over $1.8 million during a 6-month engagement at Four Seasons Ambulatory Surgery Centers.• Generated millions in new Medicare revenue through negotiations for Staff Builders Home Health Care during a 2-year engagement.• Improved clinical outcomes and risk contract performance at La Maestra CHC by applying regression analysis, resulted in an improved STAR Rating, and a 2.5% increase in patients with HeA1C < 7% over a 10-month period.• Negotiated complex managed care contracts for Molina Healthcare over a two-year period. • Applied the “pacesetter” approach with C-Suite executives to complete the ROI matrix tool (https://goo.gl/x7KRJ8) for the Michigan Primary Care Association over a 3-month period. This tool is integral to a “value-based” managed care model and is used by risk-bearing entities. • Performed 250+ compliance and technical assistant (TA) site visits to FQHCs (Federally Qualified - Health Centers) in the United States and Puerto Rico.• Led West-Coast team on a CMS-sponsored investigative research project in 4 major US markets to develop an early warning system for “steerage and discrimination” in Medicare Advantage marketing.• Executed a statewide contract after only a 30-day notice of insolvency from the incumbent laboratory provider. Negotiated, and installed a new statewide capitated contract with Unilab in 3 weeks.• Analyzed a risk contract for an east coast cluster of 9 FQHCs, a recommendation to avoid the business offering was made based on an actuarial model that was determined to be unstable.