Jovean Rivera Rivera

Results-driven healthcare leader with more than 11 years of experience in clinical operations, utilization management, case management, and health plan administration. Proven track record of building high-performing teams and developing and implementing clinical programs from the ground up across Commercial, Medicare, Medicaid, Hospice, and Palliative Care environments in Puerto Rico. Extensive experience in member engagement and provider engagement, strengthening care coordination, treatment adherence, and collaboration among patients, providers, and health plans.

Expertise in NCQA compliance, HEDIS measures, HCC risk adjustment, and data-driven quality improvement. Strong ability to integrate clinical and operational strategy to reduce costs and improve patient outcomes.

Regional Clinical Manager - Healthmap Solutions - Puerto Rico

(2023-10)

• Led full operational startup of Healthmap Solutions in Puerto Rico, defining organizational structure, workflows, and clinical protocols from inception.
• Directed and supervised multidisciplinary case management teams, ensuring alignment with NCQA and Medicare quality standards.
• Designed and implemented Tier 1–4 patient stratification model, prioritizing high-risk members and improving care coordination efficiency.
• Built interactive clinical dashboards for real-time performance monitoring, goal tracking, and executive reporting.
• Conducted regional trainings on Excel, Medicare regulations, HCC coding, ICD-10, and HEDIS measures.
• Drove member and provider engagement strategies that strengthened collaboration with medical groups and offices.
• Partnered with U.S.-based teams to standardize clinical processes and identify cost reduction opportunities.
• Performed internal audits on member and provider engagement, presenting impact analyses and improvement proposals to senior leadership.

Senior Clinical Manager - Quality Care Hospice - Puerto Rico

(2022-09 - 2023-09)

• Oversaw a clinical department of 89 staff members, including 6 Clinical Supervisors, 5 Head Nurses, 49 Visiting Nurses, and 28 Home Health Aides.
• Ensured full compliance with Medicare Hospice and Palliative Care regulations across Puerto Rico through rigorous frequency monitoring.
• Led readiness preparation for Joint Commission accreditation visit, developing strategic compliance plans.
• Authored departmental SOPs, process guides, and flowcharts to standardize quality of care delivery.
• Developed digital assessment tools for each clinical discipline, reducing documentation errors.
• Improved supply and medication delivery processes, reducing turnaround time and increasing operational efficiency.
• Produced weekly staffing reports by region to proactively address coverage gaps.
• Represented clinical leadership in interdisciplinary case conferences and patient care planning meetings.

Care Management Supervisor - Plan de Salud Menonita - San Juan, PR

(2021-12 - 2022-04)

• Supervised a 17-member Care Management team, driving performance improvements in Medicaid program operations.
• Developed a SQL-powered clinical dashboard, enabling data-driven decision-making and program oversight.
• Supported the launch of a High Cost/High Need (HCHN) unit to address complex member populations.
• Created training programs for new and existing staff, ensuring consistency in care management practices.
• Integrated member and provider engagement protocols into the HCHN program and monitored outcomes.

Care Management Supervisor / Clinical Management Analyst - Triple-S Advantage - San Juan, PR

(2018-04 - 2021-12)

• Supervised a team of 20 Case Management professionals, leading high-impact clinical initiatives that generated significant reductions in cost of care and utilization trends.
• Restructured clinical operations and implemented policies across strategic programs including CCIP, ESRD, CKD Initiative, Vascular Access, High Utilizers, and Transplant populations.
• Analyzed high-utilization member data to identify intervention opportunities and develop individualized care plans.
• Designed and maintained performance dashboards to monitor project progress, operational metrics, and staff compliance.
• Collaborated with clinical and operational teams to assess population health needs and establish program objectives aligned with payer priorities.
• Developed Disease Management Program policies, clinical reports, and structured documentation within electronic systems.
• Conducted internal and external audits supporting regulatory readiness and operational compliance.
• Integrated member engagement and provider engagement strategies throughout the end-to-end case management workflow.
• Supported clinical prior authorization processes, ensuring accurate documentation within electronic medical records.

Case Manager - Grupo Medico Clasico IPA 962 - Trujillo Alto, PR

(2015-06 - 2018-04)

• Developed a digital patient database, improving case tracking and management accuracy.
• Launched hospital discharge and care coordination programs to reduce avoidable readmissions.
• Managed Medication Therapy Management (MTM CMR) program, coordinating care plans and patient notifications.

Case Manager – Mental Health Crisis Line - APS Healthcare - San Juan, PR

(2014-10 - 2015-06)

• Coordinated mental health patient services on crisis line, ensuring timely interventions and appropriate care placement.
• Processed pre-certifications, concurrent reviews, retrospective reviews, and discharge planning.

Master of Science in Nursing (MSN) - Case Management & Administration - Universidad Ana G. Méndez (2019-05)

Bachelor of Science in Nursing (BSN) - Nursing - Universidad Metropolitana (2014-05)