Sam Cunningham Email & Phone Number

Phoenix, Arizona, United States

Serving healthcare provider and payer clients with regulatory and compliance matters.

Phoenix, Arizona, United States

Tempe, Arizona, United States

Managed 15+ engagements in FY23 resulting in over $1.2M in annual revenue.Service offerings: Independent Review Organization (Focus Arrangements), IRO-readiness, Second Validation Audit (SVA) (as part of the Affordable Care Act), Medicare Risk Adjusted Data Validation (RADV), pre-acquisition due diligence, risk assessments, coding compliance, compliance assessments, internal audit co-source support, revenue cycle denials assistance, disputes assistance and housing rental assistance.Clients include: The largest public health system in the U.S., Centers for Medicare and Medicaid Services, private equity companies, payers, providers, home health companies, group home agencies, managed care organizations, state and local agencies. Responsible for the entire engagement lifecycle from proposing on the work, executing the work, and archiving the engagements.Developed annual risk assessments and work plans for one of the largest public health systems in the country. The work also involved executing audits from the workplan which included assessing coding/billing, medical record documentation practices, preparing findings and recommendations, and facilitating corrective action plans at the direction of the Chief Compliance Officer, Chief Revenue Officer, and in-house General Counsel.Performed pre-acquisition diligence services on target healthcare organizations by assessing the coding, billing and documentation practices against regulatory requirements and industry leading practices.Directed internal assessments for healthcare organizations assessing coding, billing, documentation, focus arrangements management, training and education, auditing and monitoring, and policies and procedures maintenance.Led business development opportunities (preparing proposals, participating in oral presentations, budgeting and negotiating scope and fees) resulting in a multi-year $3.5M win for green space clients and services.

Philadelphia, Pennsylvania

Supported business development activities, which included writing point of view documents, thought leadership, opportunity identification, proposals and SOWs, oral presentations and creation of marketing material for new and existing service offerings. These pursuits resulted in growth of the existing clients and services offerings, as well as attracted opportunities for cross service line teaming resulting in $2M+ wins 45 annual engagements.Served as a subject matter resource to the largest health insurer and provider regarding payment and quality models to improve DRG, HCC, HEDIS and ICD-10-CM resulting in data analytics, dashboards and business rule development which allowed for predictive and actionable decisions by the client.Performed and managed HHS-RADV IVA services for four of the largest health plans in the southwest U.S. participating in the ACA Healthcare Exchange. The quality of the services provided allowed the health plans to receive accurate reimbursement for its patient population and financially continue to offer affordable health plans.Directed five healthcare IRO projects on the annual basis from proposing through engagement management of all work-steps in the CIA process. All IRO reports were submitted to the OIG on time and accepted by the OIG with no comments or questions.Assisted Strategy and Transaction teams with buy-side diligence and post-closure diligence for healthcare provider and payer acquisitions to identify large-scale compliance issues related to False Claims Act, Stark and Anti-Kickback Statute violations. Informed and educated clients of compliance issues as well as opportunities for revenue optimization and cost containment.

Performed production inpatient coding.

Greater Pittsburgh Area

Managed and directed over 15 direct reports both domestic and global medical coding and clerical staff. Performed production inpatient and outpatient coding and QA. • Onboarded new coding clients and performed backlog and concurrent coding• Performed ICD-9 CM/PCS production inpatient, outpatient, and same day surgery coding• Developed and worked a QA process for remote coding staff for inpatient and outpatient coding, as well as chart review auditing• Acted as a hospital’s RHIA for Joint Commission and state compliance• Consulted on the implementation of electronic medical records as well as incorporated encoding software and ICD-10 training specific to the hospital’s needs• Consulted on the development of computer assisted coding software from the coding and reimbursement perspective• Trained staff on a variety of different encoder software and electronic records• Interviewed and screened coding applicants

Conshohocken, Pa

• Audited inpatient claims for correct ICD-9 CM diagnosis and procedure codes, AP-DRG, APR-DRG, and MS-DRG• Audited outpatient claims for correct CPT-4 codes and Revenue Codes for Hospital Bill Audits• Audited claims for clinical place of service based on Milliman Care Guidelines• Created new auditing concepts and efficient queries on large data sets to maximize profitability for AP, APR and MS-DRG assignment• Managed and trained staff for both auditing, and preparing for their credential exams• Created training tutorials and procedures that are used in training new coding hires

Greater Philadelphia Area

Subcontracted at Magee Rehabilitation, I managed three in-house and two remote coders, and four full-time clerical employees. • Managed and informed the medical staff and CFO of deficient and delinquent charts. • Trained Physicians and Nurses on accurate completion of documentation using health information management systems• Written job descriptions, productivity standards, and benchmarks for coding and analysis. • Created policies and procedures for clerical jobs and streamlined tasks• Managed three part-time employees HIM projects including, scanning, record purging, and release of information• Managed the productivity and chart completion of a remote facility• Coded outpatient rehab charts