Managed Care Workers Compensation

James W. Beverly

Atlanta, Georgia

(home) ● 404-***-****

*****@*******.***

www.linkedin.com/jamesbeverly

Hospital/Physician/Ancillary Contract Negotiator

Managed Care Negotiator Consultant with over 25 years of hospital, physician, and ancillary contracting experience. Significant background application with HMO, PPO,TPA, Workers Compensation, Medicare, Medicaid (CMS) payment methodologies and contract language. Experienced Managed Care background includes building networks in most US regions either on-site or remotely.

Demonstrated value-added market research and feasibility work has resulted in revenue and profit improvements and strengthen by background in Certificate of Need (CON) experience.

PROFESSIONAL EXPERIENCE

Healthcare Consultant,

Atlanta, GA 7/2017 - Present

As a consultant, I have provided Managed Care Network Development and Contracting assistance to the following clients.

Molina Healthcare, MA 2023-2024

Negotiated 11 contracts, 38 Amendments and 12 Letters of Intent over 7 month period for Senior Whole Health “One Care”

1/1/2026 Award Proposal through Premier Healthcare Consulting.

Partners Direct Health, Texas 2021-2022

Negotiated over 70 physician and ancillary contracts resulting in new commercial member access.

Aetna Healthcare, California 2021-2022

Negotiated five hospital amendments to enter the IVL Health Exchange market for covered California on and off Exchange for

2023.

Bright Health Plan, Texas 2020-2021

Negotiated over 130 physician and ancillary Medicare Advantage contracts resulting in new Commercial and Medicare Advantage

Member access.

United Healthcare, VACCN 2019 - 2020

Negotiated 68 hospital and physician contracts.

Payor contracting consulting assistance to single- specialty clients.

OPTUM, Atlanta, GA

Network Contractor 2015 – 2017

Continued management of acquired National Ancillary network for Workers Compensation MSO in most US States. Purchased Healthcare Solutions.

HEALTHCARE SOLUTIONS, INC., Atlanta, GA

Contract Manager 2013 – 2015

Managed a National Ancillary network for Workers Compensation MSO in most US States. Led a team of two associates with

Direct oversight of network development and management activities of home health provider contracting, provider relations, and ensuring appropriate US distribution of providers.

Negotiated over 560 home health contracts in the United States to improve provider network deficiencies to sustain an adequate network for members.

Oversaw all provider relations activities improving financial cost and quality performance resolving provider access issues.

Successfully engaged and coordinated home health member provider access with clinical service nurses in US deficient locations.

Healthcare Consultant Atlanta, GA

2010 - 2013

Created network in metro Atlanta to meet Centers for Medicare & Medicaid Service (CMS) requirements for approval. Contacted by previous client, multispecialty IPA, to reintroduce managed care services; collaborated with IPA to select national Medicare advantage company with IPA serving as plan administrator; researched/approached hospitals, other IPAs, primary care, specialty and ancillary practice providers to generate interest and solicit participation; ensured individual application submission met CMS requirements. Results: Secured signing 1,256 providers and 7 hospital contracts; approval put on hold due to company’s sale (Arcadian Health Plan) to leading managed care provider.

COMMONWEALTH CARE ALLIANCE, INC. Boston, MA

Provider Network Developer 2007 - 2009

Led negotiations for Medicare Advantage Plan with dual demonstration program, Senior Care Options and Special Needs Plan (SNP). Recruited/Finalized provider contracts with providers*; developed renegotiation strategies; negotiated contract language and pricing to include fee for service, capitation and risk-share; coordinated contract execution/implementation; resolved network and contract issues; conducted meetings with key healthcare organizations, state representatives, opinion leaders and social service agencies to pave the way for future successful negotiations with major hospital facilities. Results: Finalized 50+ provider contracts; completed 45 Letters of Agreement (LOAs).

Identified ~$.5 million in financial leakage in network contracts. Analyzed network contracts; found 25% of contracts had loaded incorrectly rates; organized task force of provider network and third party claims administrator to review contracts and amend pricing with correct negotiated rates; established procedure to track and monitor implementation of new and existing contracts. Results: Improved contract implementation controls; avoided tens of thousands of dollars in future unjustified payments.

EDUCATION, PROFESSIONAL DEVELOPMENT and CIVIC

Bachelor of Science, Community Health Education

University of Massachusetts

Graduate

Boston Management Training Program through Mayor Kevin White of Boston’s office

Contributing Author

A Guide to Ethnic Minority Neighborhood Outreach, published by American Health Decisions

Volunteer

Boys Basketball Coach

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