MARC S. RIVERA
Healthcare Administrator
CA
Summary
Health Care Operations and Revenue Cycle Services
Dedicated and results-driven professional with over 20 years of experience in health care operations and revenue cycle services. Proven expertise in leveraging technology, optimizing workflows, and ensuring regulatory compliance to drive efficiency and financial success. Adept at leading cross-functional teams and implementing innovative solutions to enhance patient experiences and achieve operational excellence. Demonstrated track record in managing complex billing and coding processes, maximizing revenue capture, and improving overall revenue cycle performance.
Overview
23
23
years of professional experience
Work History
EXPERIENCE , Assistant Department Administrator
Kaiser Permanente
01.2017 - Current
- Supervises daily operations and ensures staff provide the highest quality of care and are in compliance with the Nurse Practice Act, NCQA, TJC, and federal, state and local requirements
- Implements and maintains patient care and quality service standards to meet members' and internal clients' expectations
- Acts as patient advocate resolving patient care issues
- Recommends and evaluates processes to improve systems and patient care results across the continuum of care
- Assists in developing and monitoring budgets and resource allocations
- Monitors financial performance and identifies and recommends strategies to reduce costs and improve quality of care/service
- Determines the appropriate staff mix for department and develops processes to screen, interview, hire, train, and maintain the competency of all department staff
- Assists in providing on going staff development
- Implements and monitors departmental policies and procedures which support the organization's goals and business objectives and ensures they are met
- Collaborates with physicians, department chief and nursing manager in developing the appropriate level of patient services and the day-to-day operations of the department
- Assists in managing and resolving human resource, labor relations, employee and department safety, and risk management issues.
Client Executive
CHMB, Inc
01.2016 - 01.2017
- Cultivates and fosters positive client relationships with physicians, clinicians and practice administrators
- Manages and directs client communications and CHMB service interactions
- Manages client expectations based upon Service Level Agreements
- Monitors key billing/collection statistics and compares to national/regional/local benchmarks including, but not limited to, net collections, days in A/R, etc
- Conducts meetings with Operations and others to identify areas of concern and assist in the implementation of work flow changes
- Oversees the Revenue Cycle Operations for 50+ assigned clients across the United States
- Proactive management of the client’s financial performance, delivering recommendations and results based upon financial metrics
- Works collaboratively with various departments within CHMB to resolve client concerns/requests
- Uses excellent documentation and presentation skills to develop and present interactive sessions either web or at industry shows with heavy emphasis on client success stories
Manager
Scripps Medical Foundation
01.2012 - 01.2016
- Oversees functions related to front-end access management, including, but not limited to Business Services, Patient Registration, Point-of-Service collections, insurance eligibility and benefit checking, application for financial assistance, cashiering, authorizations, and customer service support for physicians, administration, and Patient Relations
- Establishes, implements, and ensures compliance with policies and procedures related to access in accordance with accreditation and regulatory requirements
- Provides leadership to department of 32 FTE’s and indirect FTE’s at micro-site locations, ensuring high performance standards including employee, patient, and physician service excellence
- Ensures Revenue Cycle targets are met while maintaining quality and compliance requirements
- Ensures integrity of reporting and data capture as it relates to billing and collections
- Plans and organizes department goals and objectives (short and long term) and participation in budgetary planning, and managing department staffing needs
- Ensure charge encounters are submitted accurately and timely for 115+ providers
- Provide access support for new acquisitions
Supervisor
Scripps Medical Foundation
01.2011 - 01.2012
- Identify, analyze and improve operational, divisional, provider and payer processes that have or could have a negative impact to key Revenue Cycle benchmarks (Days in AR, Cash Collections, Adjustments, Missing Charges, Charge Lag, Patient Satisfaction)
- Work closely with management within Business Services and regional sites to improve and streamline processes that directly impact revenue and patient satisfaction
- Work closely with the coding department on the creation of TES and/or Claims Manager edits
- Implementation of routine reports via Oracle, DBMS and/or Cognos to efficiently work and prevent invoices from aging on the outstanding accounts receivable (AR)
- Review, analyze and distribute outstanding AR to staff for insurance follow up
- Responsible for reducing the AR through collections or adjustments
- Training and developing of staff on insurance follow up policies and procedures
- Locating and reviewing clinical policy bulletins, claims payment policies and pre-certification lists for medical necessity/investigational, coding and no authorization denials management
- Submission of mass appeals to Commercial health plans for various denial types
Access Training & Development Specialist
Scripps Medical Foundation
01.2010 - 01.2011
- Analyze outstanding AR and provide recommendations to senior management regarding techniques that can efficiently reduce the AR
- Develop job guides and training materials for all units within Business Services
- Mentoring of new Access Representatives in the department
- Identify and implement solutions on key issues that prevent Scripps Medical Foundation from maximizing reimbursement
- Manage projects requiring coordination between multiple business units on complex billing issues
- Provide research support for the Provider Relations, Finance and Reimbursement teams
Regional Account Manager
AIM Healthcare
01.2007 - 01.2010
- Perform on-site credit balance reviews in the hospital and clinic sector
- Knowledge of insurance payer contracts and reimbursement methodologies
- Reviewing, analyzing, and recovering overpayments made to providers
- Assist hospitals and/or clinics in determining whether credit balances are a result of an overpayment or contractual adjustment error
Care Specialist, Claims Lead;, •CNA/Unit Clerk
Sharp Healthcare
01.2002 - 01.2007
- I, II & III;, Coordinate, review, and process complex referrals for prior authorization
- Obtain health plan criteria and medical records for review
- Attend hospital rounds with the Hospitalist physicians to acquire information on patient’s possible discharge needs
- Process Senior and Commercial claims for multiple lines of business
- Perform audits on all claims processors, provide training, and implement performance improvement plans when appropriate
- Process electronically filed HCFA and UB claims
- Follow all departmental procedures to ensure that all fee-for-service and capitated claims are processed in a timely manner
- Responsible for appeals, adjustment requests, and customer service requests
Education
Bachelors Of Science - Healthcare Administration
University of Phoenix
Tempe, AZ12.2022
Skills
SKILLS PROFILE
- Proficient in
- Microsoft Office
- Report Preparation and Analysis
- Financial Management
- Data Analysis and Modeling
- Ambulatory Care
- Leadership and Change Management
- Proficient in creating complex Oracle & Cognos queries
- Analytics/Research knowledge with an emphasis on Healthcare Business Operations
- Knowledge of multiple Practice Management/EHR platforms ie IDX, Allscripts, EPIC
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
EXPERIENCE , Assistant Department Administrator
Kaiser Permanente
01.2017 - Current
Client Executive
CHMB, Inc
01.2016 - 01.2017
Manager
Scripps Medical Foundation
01.2012 - 01.2016
Supervisor
Scripps Medical Foundation
01.2011 - 01.2012
Access Training & Development Specialist
Scripps Medical Foundation
01.2010 - 01.2011
Regional Account Manager
AIM Healthcare
01.2007 - 01.2010
Care Specialist, Claims Lead;, •CNA/Unit Clerk
Sharp Healthcare
01.2002 - 01.2007
Bachelors Of Science - Healthcare Administration
University of Phoenix
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